Print Form Michigan Department of Licensing and Regulatory Affairs MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 CHANGE OF NAME STATEMENT INSTRUCTIONS: The licensee must complete and return this statement to change the license record. If a new spouse is being "added" to the license please request change of license forms by calling 517-322-1345 (the necessary form you receive will correspond to the type of license held). This form is authorized by the Michigan Liquor Control Act, PA 85 of 1998 as amended. I, _____________________________________, of _____________________________________________ ADDRESS STREET and NUMBER LICENSEE _______________________________________________________________________________________ CITY OR VILLAGE ZIP CODE COUNTY Make the following statements to the Michigan Liquor Control Commission as my request to change my name from ____________________________________________ to _________________________________________ PREVIOUS NAME MARRIED NAME on __________________________________________________________________________________ TYPE OF LICENSE and agree that every statement below is true to the best of my knowledge and belief. 1. Neither I, nor my spouse hold any position, either by appointment or election, which involves the duty to enforce any penal laws of the United States of America, or the penal laws of the State of Michigan (civil defense volunteer policemen, mayors, village presidents, and members of the city councils are not considered to be law enforcement officers). 2. Neither I, nor my spouse hold any type of license for the manufacture or sale of alcoholic beverages at wholesale in Michigan, nor any interest (stockholder) in any class of license for the sale of alcoholic liquor in Michigan which would be in conflict with the granting of this license(s). 3. I understand that the falsification of the information on this form may constitute grounds for denial or revocation of the license(s). Signature of Licensee Date LC-46 (Rev.04/11) AUTHORITY: MCL 436 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