Michigan Department of Licensing and Regulatory AffairsLiquor Control Commission (MLCC) Toll-Free: 866-813-0011 - www.michigan.gov/lcc Business ID: Request ID:(For MLCC Use Only)Broker License ApplicationPart 1 - Applicant Information Corporations or Limited Liability Companies, please state your name as it is filed with the State of Michigan Corporation Division.Applicant name:Address:City:Zip Code: LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LCC-154 (02-16)For information on manufacturer and wholesaler licenses and permits, including a checklist of required documents for a completed application, please visit the Liquor Control Commission's frequently asked questions website by clicking this link .Federal Employer Identification Number (FEIN):Email:Phone:Contact Name:Part 2 - License Fee & Required Documents $35.00 License Fee - Make check payable to State of Michigan (MLCC Fee Code 4038) Copy of Broker Agreement executed between the applicant and the company to be represented. Copy of Articles of Incorporation or Articles of Organization with Operating Agreement. Not required if the applicant is currently or has been previously licensed by the MLCC. Report of Stockholders, Members, or Partners (LCC-301). Not required if the applicant is currently or has been previously licensed by the MLCC.Has the applicant ever been denied a license or had a license revoked by the MLCC? Yes NoIf Yes, please explain (attach additional sheet if necessary):A Broker License only applies to a company who represents a Vendor of Spirits, Brewer, Wine Maker, Outstate Seller of Beer, Wine, or Mixed Spirit Drink, or a Wholesaler licensed by the Commission where the company is to act as the Michigan broker to aid and assist the supplier in the sale, delivery or promotion of alcoholic liquor.Part 3 - Signature of Applicant (Broker) I certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I agree to comply with all requirements of the Michigan Liquor Control Code and Administrative Rules. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.2003. Print Name & Title of Applicant Applicant Signature DateName of company to be represented by applicant: Please return this completed form along with corresponding documents and fees to: Michigan Liquor Control Commission Mailing address: P.O. Box 30005, Lansing, MI 48909 Hand deliveries or overnight packages: Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Fax to: 517-373-4202 American LegalNet, Inc. www.FormsWorkFlow.com Credit Card Authorization FormMichigan Department of Licensing and Regulatory Affairs Finance and Administrative Services Revenue Services Name: Card Number: Expiration Date: Address: City: State: Zip Code: Phone: Payment is for: Applicant/Licensee Name: Request or Business ID #: Transaction Amount: Discover MasterCard VisaCheck One: Signature * * FAX COMPLETED FORM TO SECURE FAX LINE: 517-373-4202 * * * * DO NOT EMAIL OR MAIL THIS FORM * * Requests with credit card payments that are not faxed to the above secure fax line will be destroyed along with the credit card authorization in order to ensure the security of applicants222 personal credit card numbers. * *IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED* *LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LCC-300 (06-17)IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED. Credit Card Payment Itemization: Special License Fee(s): Sunday Sales Permit (AM): Sunday Sales Permit (PM): Catering Permit: New Add Bar Transfer Add Bar: License Renewal Fee(s): New Retailer License(s): Manufacturer License(s): Transfer Retailer License(s): Temporary Authorization Fee: Inspection Fee(s): Fee AmountMLCC Fee Code40364008403740044038401240344033403240314012/4034Fee Type4085 Wholesaler License(s): LARA Revenue Services is not a part of the Michigan Liquor Control Commission (MLCC). Receipt of payment and application forms by LARA Revenue Services does not constitute receipt of an applicationby the MLCC. Applications submitted through LARA Revenue Services may take up to two (2) additional business days to be received by the MLCC after receipt by LARA Revenue Services. For requests that require a timely receipt of an application by the MLCC to be processed, such as Special Licenses and temporary requests, please ensure that your application will be received in adequate time to be processed by the MLCC after the payment is received and processed by LARA Revenue Services. LARA Revenue Services is not a part of the Michigan Liquor Control Commission (see note below). Conditional License 4012 American LegalNet, Inc. www.FormsWorkFlow.com