Michigan Department of Labor & Economic Growth MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005, Lansing, MI 48909-7505 Application for Hospital Liquor Permit FOR THE PERIOD MAY 1, 2005 TO APRIL 30, 2008 (Authorized by MAC 436.1251) GENERAL INSTRUCTIONS • • • This application must be completed by hospitals who purchase liquor for medicinal purposes. Check whether this application is for a new permit or renewal of an existing permit, and enter the information requested. Photocopy the completed application for your files. Return the original to the address at the top of this form. TO BE COMPLETED BY APPLICANT 1. Check type of application:_____ Renewal ____ New 2. Name of Hospital 6. Michigan Department of Public Health License No. ______________________________________ 3. Street Address 7. Expiration of Hospital License 4. City, State, Zip Code 8. Number of Hospital Beds 5. Business Telephone No. 9. Annual amount of alcoholic liquor requested ( ) (750 ML Bottles) • This hospital requests that the MLCC grant a PERMIT to purchase alcoholic liquor over 21% alcohol by volume. • The alcoholic liquor purchased under this PERMIT is to be used for medicinal purposes only and dispensed on the prescription or order of a licensed physician. WARNING: Making false or fraudulent statements to the Liquor Control Commission is a violation of the Liquor Control Code, and is punishable by fine, suspension, or revocation of the license or permit. I declare that the information I have provided is true and that I understand the Warning. Signature: _______________________________________________________________________________ Title: ____________________________________________________ Date: __________________________ LC-MW-659 Rev. 02/05 AUTHORITY: MAC 436.1251 COMPLETION: Mandatory for Permit PENALTY: No Permit Issued 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