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 VENDOR REPRESENTATIVE LICENSE For the period May 1, 2005 to April 30, 2008 Please TYPE or PRINT INSTRUCTIONS 1. Name of Applicant WHO MUST FILE – The person representing the Vendor of Spirits with the Commission. Each Vendor of Spirits must have one and only one Vendor Representative. 2. Home Address (number, street, city, state, zip code) CHANGE IN EMPLOYMENT – Notify the MLCC. Licenses will be transferred or put into escrow at no charge. 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. 3. Home Telephone Number 4. Business Address (number, street, city, state, zip code) FILING THE APPLICATION a. Make photocopies for your records b. Print applicant name in the space at the bottom of the form. c. Mail the application and a check for $50 (payable to the STATE OF MICHIGAN) to the above address. 5. Business Telephone Number 6. EMAIL Address *You MUST inform the Commission of any change to your email address.* To be completed by APPLICANT 7. Date of Birth CHECK TYPE OF LICENSE: ___ New License $50 ___ Transfer License (No Fee) 9. Have you ever been licensed by the MLCC? __ No __Yes: If yes indicate type of license and Year: 8. Driver’s License No. 10. Have you ever been denied a license by the MLCC? __ No __ Yes: If yes list facts, dates and places on a separate sheet. 11. Do you or your spouse hold (or have financial interest in) a RETAIL license? __ No 12. Have you ever been arrested or convicted? __ No __ Yes: If yes list licenses and places. __ Yes: If yes list facts, dates and places on a separate sheet. 13. 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 VENDOR OF SPIRITS 14. Name and Address of employer authorized to do business in Michigan: 15. Business Telephone Number 16. FEDERAL ID Number 17. I request the MLCC grant a VENDOR REPRESENTATIVE LICENSE to: _______________________________ Signature: LC-MW-843a (Rev. 02/07) AUTHORITY: MAC 436.1853 COMPLETION: Mandatory for license PENALTY: No 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