Print Form Michigan Department of Energy, Labor & Economic Growth FOR MLCC USE ONLY MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 Business ID #____________ APPLICATION FOR DIRECT SHIPPER LICENSE License #_______________ Date Issued _____________ [Authorized by MCL 436.1203] ___________________________________________________________________________________________________ GENERAL INSTRUCTIONS • • • A Direct Shipper License only applies to a licensed manufacturer of wine who ships domestic wines to Michigan consumers. It does not allow the direct shipment of imported wines. To be considered for a license you must complete this application, sign the form, and attach all required documents. Return the application with all required documents and a check payable to the State of Michigan for the $100.00 license fee to the address at the top of this form. MAKE A COPY OF THIS APPLICATION FOR YOUR FILE. The license renews annually by May 1 of each year and the annual license renewal fee is $100.00. The license is effective May 1 through April 30. License fees are not prorated. PART 1. APPLICANT INFORMATION 1. Check type of business: Limited Liability Company - Corporation - Partnership - Individual 2. Full name of Limited Liability Company, Corporation, Partnership or Individual: 3. D.B.A. (Business Name and not Trade Names): 4. Street Address: 5. City: 6. State: 7. Zip Code: 8. Indicate the state in which you are licensed to manufacture wine and attach a copy of the licence. If you are a licensed winemaker in Michigan, enter your license number here and proceed to Part 3. 9. Attach a copy of your Federal Basic Permit issued by the Tax and Trade Bureau (TTB). Note: The Federal Basic Permit must be in the same name as the license to manufacture wine issued by the State 10. Business Telephone Number: 11. Email Address: 12. Federal Employer Identification Number (FEIN): 13. CORPORATE/LIMITED LIABILITY COMPANY APPLICANTS ONLY: State of Incorporation/Organization: Corporation/Limited Liability Company Status: Corporate Officers: NAME Profit or ADDRESS Non-Profit and Public or Private TELEPHONE NUMBER President: Vice-President: American LegalNet, Inc. www.FormsWorkFlow.com CORPORATE/LIMITED LIABILITY COMPANY APPLICANTS (CONT'D) Secretary: Treasurer: Authorized Signors*: *Only those person(s) listed may sign this Application for Direct Shipper License and Renewal Applications 14. PARTNERSHIP APPLICANTS ONLY: Indicate all Limited Partners with L Name of Partners PART 2 Home Address % of interest DISCLOSURE OF INTEREST IN A MICHIGAN LICENSE Do you have any interest, financial or otherwise, directly or indirectly, in the business of any retailer, manufacturer, wholesaler, or vendor of spirits in Michigan? NO Yes - If Yes, please explain on an attached sheet. PART 3 ALL PARTNERS AND GENERAL PARTNERS OF LIMITED PARTNERSHIPS MUST SIGN THE CONTRACT FOR LICENSE. AUTHORIZED CORPORATE OFFICERS OR AUTHORIZED MEMBERS OR MANAGERS OF THE LIMITED LIABILITY COMPANY MUST SIGN THE CONTRACT FOR LICENSE. • • • • I agree to abide by all provisions of the Michigan Liquor Control Code (P.A. 58 of 1998) and all the rules of the MLCC. I authorize the MLCC to investigate records of this business to determine license qualifications. I swear that all the answers on this application are true, that the applicant is the sole owner of the business and that submitting false or incomplete information is cause for denial of the license and is a violation of the Michigan Liquor Control Code of 1998. I swear that the hereinbefore described applicant is a bona fide company with sufficient financial resources to comply with the proof of financial responsibility requirements and the tax requirements of the Michigan Liquor Control Code of 1998. SIGNATURE OF APPLICANTS TITLE HOME ADDRESS X X X X REMINDER TO ENCLOSE A CHECK MADE PAYABLE TO THE "STATE OF MICHIGAN" FOR THE AMOUNT OF THE LICENSE PLUS ANY ADDITIONAL REQUIRED DOCUMENTS. LC-MW110 (Rev. 12/10) Authority: MCL 436.1203 Completion: Mandatory Penalty: No License The Department of Energy, 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