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 SALESPERSON LICENSE For the period May 1, 2005 to April 30, 2008 Please TYPE or PRINT 1. Name of Applicant INSTRUCTIONS WHO MUST FILE – Persons who sell, promote, deliver or otherwise assist in the sale of alcoholic liquors in Michigan. CHANGE IN EMPLOYMENT – Notify the MLCC. Licenses will be transferred or put into escrow at no charge. 2. Home Address (number, street, city, state, zip code) 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. FILING THE APPLICATION a. Make photocopies for your records b. Mail the application and a check for $35 (payable to the STATE OF MICHIGAN) to the above address. 5. Business Telephone Number CHECK TYPE OF LICENSE: To be completed by APPLICANT 6. Date of Birth 7. Driver’s License No. ___ New License $35 ___Transfer License (No Fee) 8. Have you ever been licensed by the MLCC? __ No __Yes: If yes indicate type of license and Year: 9. Have you ever been denied a license by the MLCC? __ No __ Yes: If yes list facts, dates and places on a separate sheet. 10. Do you or your spouse hold (or have financial interest in) a RETAIL license? __ No __ Yes: If yes list licenses and places. 11. Have you ever been arrested or convicted? __ No __ Yes: If yes list facts, dates and places on a separate sheet. 12. 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 (do not write in this space) Date: To be completed by EMPLOYER 13. Name and Address of employer authorized to do business in Michigan: 14. Business Telephone Number 15. FEDERAL ID Number 16. I request the MLCC grant a SALESPERSON LICENSE to: _________________________________________ Signature: LC-MW-843 (Rev. 02/05) AUTHORITY: MAC 436.1853 COMPLETION: Mandatory for license PENALTY: No Salesperson 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