Credit Card Authorization Form
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Credit Card Authorization Form. This is a Michigan form and can be use in Liquor Control Commission Statewide.
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Tags: Credit Card Authorization Form, LC 65, Michigan Statewide, Liquor Control Commission
Michigan Department of Licensing and Regulatory Affairs
Michigan Liquor Control Commission (MLCC)
www.michigan.gov/lcc
Name:
Address:
City:
State:
Zip Code:
CREDIT CARD AUTHORIZATION FORM
FAX completed form to secured number:
517-322-5237
Transaction Amount:
Credit Card Number:
Check one:
MasterCard
Expiration Date:
This Payment
is for:
Signature:
Notice: This form may be used for payment of goods and services offered by the Michigan Liquor Control Commission,
with the exception of the purchase of alcoholic beverages.
LC-65 (Rev. 04/11)
AUTHORITY: MCL 436.1525
LARA is an equal opportunity employer/program.
Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
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