Michigan Department of Labor & Economic Growth MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, MI 48909-7505 MLCC USE ONLY License No. ____________________ Date Issued ____________________ APPLICATION FOR BROKER LICENSE For the period May 1, 2005 to April 30, 2008 Please TYPE or PRINT INSTRUCTIONS 1. Name of Applicant WHO MUST FILE – Any company who represents a Vendor of Spirits, Brewer, Wine Maker, Outstate Seller of Beer, Wine, or Mixed Spirit Drink, or a Wholesaler licensed by the Commission, where the company is to act as the Michigan broker or to aid and assist the supplier in the sale, delivery or promotion of alcoholic liquor. 2. Home Address (number, street, city, state, zip code) CHANGE IN EMPLOYMENT – Notify the MLCC when the Applicant named on this form terminates their relationship with the Vendor of Spirits, Supplier or Wholesaler. 3. Home Telephone Number 4. Business Address (number, street, city, state, zip code) PENALTIES – Failure to obtain a required license is a violation of the Liquor Control Code. Submitting FALSE or INCOMPLETE information is also a violation. Violation of the Code may result in denial, suspension or revocation of the license and a fine. 5. Business Telephone Number FILING THE APPLICATION a. Make photocopies for your records b. Print applicant name in the space at the bottom of the form. c. Mail the application and a check for $35 (payable to the STATE OF MICHIGAN) to the above address. CHECK TYPE OF LICENSE: ___ New License $35 ___ Transfer License (No Fee) Note: Corporations or Limited Liability Companies filing for the first time must submit the following additional documents. A. A copy of the current Articles of Incorporation, or Article of Organization, as approved by the Michigan Department of Consumer & Industry Services, Corporate Division. B. Report of Corporate Officers, Board of Directors, and Stockholders (form LC-52) or Report of Limited Liability Company Members, Managers and Assignees (form LC-52a). To be completed by APPLICANT 6. Has the Michigan Liquor Control Commission previously issued a license to this Company? ____ No ____ Yes If YES, please list the Type of License ____________________ Year Issued __________ License No. ______________ 7. Has the company ever been denied a license or had a license revoked by the MLCC? If yes list facts, dates and places on a separate sheet. ____ No ____ Yes 8. By signing this application I agree to abide by the provisions of the Liquor Control Code and the Administrative Rules of the MLCC. I also understand that submitting FALSE or INCOMPLETE information is cause for denial of the license and is a violation of the Liquor Control Code. Signature: CASHIER VALIDATION (please do not write in this space) Date: To be completed by Company to be represented by BROKER 9. Name and Address of Company: 10. Business Telephone Number 11. FEDERAL ID Number 12. I request the MLCC grant a BROKER LICENSE to: _______________________________________________ Signature: LC-MW-843c (Rev. 02/05) AUTHORITY: MAC 436.1853 COMPLETION: Mandatory for license PENALTY: No License Issued Title: Date: The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkflow.com