Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Mailing Address: PO Box 30005, Lansing, MI 48909 Toll Free (866) 813-0011 • www.michigan.gov/lcc Business ID: Request ID: (For MLCC use only) APPLICATION FOR SPIRIT CONSUMER SAMPLING EVENT LICENSE [Authorized by MCL 436.2027] GENERAL INSTRUCTIONS • A Spirit Consumer Sampling Event License only applies to a Vendor of Spirits or a licensed Manufacturer of Spirits, Small Distiller, or Brandy Manufacturer. To be considered for a license you must complete this application, sign the form, and attach any required documents. Return the application with all required documents and a check payable to the State ofMichiganfor the $70.00 license fee to the address at the top of this form. MAKE A COPY OF THIS APPLICATION FOR YOUR FILE. The license renews triennially, or every three years, by May 1. The license renewal fee is $70.00. The license is effective May 1 through April 30. The next triennial cycle will begin May 1, 2014 through April 30, 2017. 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. Enter your license number or Vendor Code Number: 9. Business Telephone Number: Mobile Telephone Number: 10. Email Address: PART 2 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 of the Michigan Liquor Control Code of 1998. • SIGNATURE OF APPLICANTS X TITLE ADDRESS X LC-MW-1000 Authority: MCL 436.1203 Completion: Mandatory Penalty: No License LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com