Print Form Michigan Department of Licensing and Regulatory Affairs FOR MLCC USE ONLY LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 APPLICATION FOR NEW LICENSES, OR APPLICATION OF BUYERS FOR TRANSFER OF OWNERSHIP OR INTEREST IN LICENSE Instructions: This application must be completed and returned with a $70.00 inspection fee for each license before it can be considered. All answers must be typed or printed. Sign the completed form in ink and return it to the Commission with the inspection fee. MAKE ALL CHECKS OR MONEY ORDERS PAYABLE TO "STATE OF MICHIGAN". 1. Applicant Identification - all applicants Name of individual, partnership, corporation or limited liability company who will hold the license: Contact Person Name: Business Street Address: Street Address: City / State / Zip Code: City / State / Zip Code: Township: County: Business Phone No. New License Transfer of Ownership - NAME of current Licensee: New Permit Home Phone No. Transfer Location From ADDRESS: TOWNSHIP and COUNTY: Add Partner Drop Partner Add Space Stock Transfer Transfer Status from Individual or Limited Partnership to a Corporation Transfer Classification Tavern to Class C Class C to Tavern Drop Space B-Hotel to Class C Other : Class C to B-Hotel 3. Retail Applicants - (All existing permits will be included with a transferred license unless cancelled in writing) 3b. Check Type of Permits 3a. Check Type of License Sunday Sales Before or After Hours For: SDM SDD Resort Class C Add Bar Class C Dance Resort A-Hotel A-Hotel ( Food, Bowling, Golf, Ski, Misc.) Dance/Entertainment Resort B-Hotel B-Hotel Topless Activity Outdoor Service Resort Tavern Direct Connection Tavern Resort G-1 Club Living Quarters Resort G-2 G-1 Other: G-2 4. New Manufacturer or Wholesale Applicants (Check one) Wholesaler Wine Maker Small Wine Maker Wine Maker Wine Tasting Room Micro Brewer Brewer Manufacturer of Spirits Industrial Manufacturer Warehouse Brewpub Manufacturer of Mixed Spirit Drinks Outstate Seller of Mixed Spirit Drinks Outstate Seller of Wine Outstate Seller of Beer Other: 5. Names of Current Licensees: 6. Current Licensed Address: 7. Proposed Licensed Address: 8. Briefly describe this business, for instance - Drug Store, Restaurant, Party Store, Wholesaler, Wine Maker, Etc. LC 687 Rev. 04/11 American LegalNet, Inc. www.FormsWorkFlow.com (Page 1 of 4) 9. This proposed licensed business will be owned by: (check one) Me as the individual owner The named corporation The named Liability company The following partners (indicate limited partners with an "L" before their name) Partnership Information: (attach additional sheet if necessary) Name of Partners Home Address Phone Number * All general partners must complete & submit an LC 621, "Individual, General Partner, Stockholder or Member Questionnaire." All limited partners must complete & submit an LC 38, "Limited Partner, Stockholder or Member Statement." 10. Personal Information - Individual Applicants and Partnership Members Only Sex Height Weight Hair Color Date of Birth Place of Birth Eye Color Social Security No. If you are not a US Citizen - Are you a registered alien? Yes No Or, Do you have a Visa? Yes No Full name of spouse: Have you ever legally changed your name? Yes No If Yes, FROM TO No List names: Have you been known by other names? Yes Have you ever been arrested? No If Yes, list all arrests, excluding minor traffic offenses (include alcohol arrests): DATE Yes PLACE List your former occupations for the past 3 years: From-To DATES OCCUPATION mm-dd-yyyy format CHARGE DISPOSITION * attach additional sheet if necessary EMPLOYER NAME AND ADDRESS to to to I or my spouse previously held or now hold interest in the following licenses for sale of alcoholic beverages as sole licensee, partner or corporation: NAME OF LICENSEE TYPE OF LICENSE LOCATION DATE Do you or your spouse hold any law enforcement powers including powers of arrest? Yes No 11. Limited Partnerships-is the limited partnership authorized to do business under the laws of Michigan? Yes No Date authorized: 12. Corporate & Limited Liability Company Applicants Only - stockholders/members must complete a separate survey Note: Attach copy of filed/proposed Articles of Incorporation, last annual report/statement filed & attach copy of stock options. Corporate/LLC Name: Incorporated/Organized in what State? Alabama Person(s) authorized to sign the application and any documents required by the MLCC: American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 4) (Check one of each) Profit or Non-profit Corporation Public or Private Corporation Date last annual report / statement filed with Michigan Corporation & Securities: Corporate Officers: NAME ADDRESS PHONE NUMBER President Vice-President Secretary Treasurer 13. Corporations and Limited Liability Companies - List all persons, companies and other entities who hold or will hold stock interest or membership interest in applicant entity. NAME ADDRESS PHONE # % INTEREST 1. 2. 3. 4. 5. *Note: All persons, companies and other entities holding 10% interest or more must complete and submit an "Individual, General Partner, Stockholder or Member Questionnaire" (LC-621). All persons, companies and other entities holding less than 10% interest, must complete and submit a "Limited Partners, Stockholders or Members Statement" (LC-38). 14. Financial Details - All Applicants (A) Source of funds used to establish business, or which will be used to purchase this business, list name address and amount of all money lenders. Money lenders to fill out special "Statement of Money Lender" form enclosed. Address Name Amount $ $ $ (B) Attorney or representative Address Phone Number Name Address Phone Number Name Address Phone Number Address Phone Number Address Phone Number Name (C) Real estate is owned by (D) Realtor/Broker Name (E) Accountant or Bookkeeper Name (Page 3 of 4) American LegalNet, Inc. www.FormsWorkFlow.com 15. Transaction Details - All Applicants Note iAny balance owed on the business selling price must be secured by a non-title retaining instrument such as a promissory note, security agreement, etc. iLand contracts are not acceptable as security for any unpaid balance to be owed on the business portion of the sale. iBusiness, fixtures and equipment cannot be listed on land contracts or real estate mortgages. iAll alcoholic beverage inventory must be paid for in cash at the time of transfer and not by installment payments. iAcceptable lease agreements must be provided if ownership of real estate is not in the names of applicants. iPurchasers of "ON-PREMISES" licensed establishments are required to have 10% of the purchase price for the licensed business, excluding real estate, in their own funds. Business/Fixtures/Equipment $ Land $ Goodwill (if applicable) $ Building(s) $ Covenant not to compete (if applicable) $ Other $ Alcoholic beverages (estimate) $ TOTAL REAL ESTATE COSTS $ Other inventory (estimate) $ Down Payment $ TOTAL COST OF BUSINESS $ BALANCE OWED $ Down Payment $ Secured by $ BALANCE OWED $ For balance owed - explain: For balance owed - explain: hTerms: iTerms: iCollateral: iCollateral: The Commission wishes to warn all applicants for licenses not to invest any money or to commit themselves by any binding agreements in the expectation of being issued a license for sale of alcoholic beverages until officially notified by the Commission that their application has been approved. WARNING! Section 436.2003 of the Liquor Code provides: "A person who makes a false or fraudulent statement to the commission, orally or in writing, for the purpose of inducing the commission to act or refrain from taking action, or for the purpose of enabling or assisting a person to evade the provisions of this act is guilty of a violation of this act and is punishable in the manner provided for in section 909. Further, the rules and regulations of the Commission entitled "General Rules" provide: "A licensee shall not obtain a license for the use or benefit of another person whose name does not appear on the license nor shall a licensee allow a person whose name does not appear on the license to use or benefit from the license," and, "A licensee shall not sell or transfer an interest in a business licensed by the Commission without the prior written approval of the Commission." I hereby authorize investigators of the Michigan Liquor Control Commission to obtain all documents, accounts, books, records and tax returns pertaining to myself and this business. I hereby swear that I have read all of the above answers and that they are true and further that I have read and understand the warning. Application Date (MM/DD/YYYY) LC-687 (Rev. 04/11) AUTHORITY: MAC R436.1103 COMPLETION: Mandatory PENALTY: No license granted ____________________________________ Signature of Applicant Name of person completing this form if not the applicant (if applicant is a corporation, include title of signor) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. (Page 4 of 4) American LegalNet, Inc. www.FormsWorkFlow.com