Michigan Department of Labor & Economic Growth MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 FOR MLCC USE ONLY License #: ____________ Date Issued: ___________ APPLICATION FOR MICHIGAN NON-RETAIL LICENSE [Authorized by MAC R 436.1103] _________________________________________________________________________________________________ GENERAL INSTRUCTIONS • • • To be considered for a license you must complete this application. Complete the required information in all PARTS of this application, sign the form, and attach all required documents. Return the application with all required documents and a check made payable to State of Michigan for the appropriate LICENSE FEE to t he address at the top of this form. MAKE A COPY OF THIS APPLICATION FOR YOUR FILE. These licenses renew annually by May 1 of each year. The license is effective May 1 through April 30. License fees are not prorated. PART 1. APPLICANT INFORMATION NEW license 1. Check type of application: 2. Check type of business: Government TRANSFER of existing license Limited Liability Company 3. Applicant Name: Corporation Partnership Individual 4. D.B.A. (Business Name) 5. Street Address: 6. City 7. State: 8. Zip Code: 9. County: 10. Township: 11. Business Telephone Number: 12. Federal Employer ID No.: 13. Email Address: PART 2. LICENSE INFORMATION TYPE OF LICENSE PLEASE ANSWER ALL QUESTIONS AND CHECK APPROPRIATE BOXES FEE Outstate Seller of Wine $ 300 Outstate Seller of Mixed Spirit Drink $ 300 Outstate Seller of Beer $ 1,000 PLEASE ANSWER ALL QUESTIONS AND CHECK ALL BOXES THAT APPLY Import foreign product and ship to Michigan Wholesalers Produce and bottle own product Ship and sell bulk product to Michigan manufacturers for blending and rectifying purposes or for non-beverage purposes Sell bottled product to minister, priest or rabbi for sacramental purpose Bottle product produced by another person Own the product, manufactured by someone else Have been designated as the sole and exclusive sales agent in the U.S. by the manufacturer of the product (not an imported product) Purchase product from a U.S. Manufacturer, not to exceed 150,000 liters per manufacturer per calendar year. Country or State of origin of shipments to Michigan: _______________________ Located in the U.S. (Including MI) and import and sell foreign beer to MI wholesalers Located outside MI, but inside U.S., and manufacture and package own beer for sale to MI wholesalers Designated as the sole and exclusive sales agent in MI by the manufacturer of the beer, not to exceed 5,000 barrels per manufacturer per calendar year Source of origin of shipments to Michigan: _______________________________ CASHIER VALIDATION (Do not write in this area) LC-MW-100 (Rev. 10/2007) American LegalNet, Inc. www.FormsWorkflow.com PART 2. LICENSE INFORMATION (continued) TYPE OF LICENSE FEE Wholesale Vendor of Beer and/or Wine $ (Enter Amount) PLEASE ANSWER ALL QUESTIONS AND CHECK APPROPRIATE BOXES Determine license fee as follows and enter at left: • $300.00 license fee $300.00 • Enter total number of RETAIL delivery vehicles ____ • License fee includes one RETAIL delivery vehicle – 1 • Each additional delivery vehicle is $50.00 X ___ = + _______ TOTAL LICENSE FEE $ ______ Warehouser $ 50 None Industrial Manufacturer $ 10 Do you want to purchase from: State Seller of Alcohol Licensee Please state use of alcohol __________________________________________________ Will alcohol be a part of a finished product? Yes No $ 10 Do you want to purchase alcohol from: State Seller of Alcohol Licensee Please state use of alcohol __________________________________________________ For Resale? Yes No Seller of Alcohol $ 10 Country/State of origin of shipments to Michigan: _________________________________ Michigan Spirit Manufacturer $ 1,000 None Michigan Manufacturer of Mixed Spirit Drink $ 100 None Michigan Brewer $ 50 Michigan Micro Brewer $ 50 Michigan Wine Maker $ 100 Michigan Small Wine Maker $ 25 Michigan Brandy Manufacturer $ 100 Must be held in conjunction with Michigan Wine Maker or Small Wine Maker license. Michigan Wine Maker Tasting Room $ 100 Must be held in conjunction with Michigan Wine Maker or Small Wine Maker license. Limited Alcohol Buyer PART 3. DISCLOSURE OF INTEREST IN A MICHIGAN LICENSE 14. 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. ALL APPLICANTS MUST SIGN THIS FORM. IF THE LICENSE IS TO BE HELD BY A CORPORATION, OFFICERS AUTHORIZED TO SIGN AND EXECUTE DOCUMENTS MUST SIGN. • • • I agree to abide by all provisions of the Liquor Control Code (P.A. 58 of 1998) and all the rules and regulations of the MLCC I authorize the Liquor Control Commission to investigate records of this business to determine license qualifications. I swear that all the answers on this application are true and that I understand submitting FALSE or INCOMPLETE information is cause for denial of the license and is a violation of the Liquor Control Code. SIGNATURE OF APPLICANTS TITLE HOME ADDRESS ► REMINDER TO ENCLOSE A CHECK MADE PAYABLE TO THE “STATE OF MICHIGAN” FOR THE AMOUNT OF THE LICENSE AND INCLUDE ALL ADDITIONAL REQUIRED DOCUMENTS LC-MW-100 (Rev. 10/2007) Authority: MAC R 436.1103 Completion: Mandatory Penalty: No License 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