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 FAST TRACK INITIAL APPLICATION MLCC USE ONLY - DO NOT WRITE IN THIS SPACE Licensee Business ID#: Licensee Request ID#: Applicant Business ID#: Applicant Request ID#: COMPLETE ALL INFORMATION IN THIS SECTION: Applicant (Buyer): ____________________________________________________ (Name of Individual, Partnership, Corporation or Limited Liability Company) Business Address of currently licensed location (number and street): ____________________________________ City or Village _______________*Township _________________ County _____________ Zip Code ___________ * You must indicate Township if business is located outside of City or Village limits. Current Licensee (Seller): ______________________________________________________________________ (Name of Individual, Partnership, Corporation or Limited Liability Company) DBA: (assumed name of business): _______________________________________________________________ Business Telephone:( ) ____________ Type of License: ______________ License Number: ______________ IF THE BUSINESS IS NOT CURRENTLY LICENSED YOU ARE NOT ELIGIBLE TO PARTICIPATE IN THE FAST TRACK APPLICATION PROCESS AT THIS TIME. Do you currently hold a retail license for the sale of alcoholic beverages in Michigan? ___Yes ___ No * (*If no, please see the next question to determine if you are eligible to participate in the Fast Track Application process) Did you previously hold a retail license for the sale of alcoholic beverages in Michigan in the preceding 12 Months? ___Yes ___No * (*If no, you are not eligible at this time to participate in the Fast Track Application process.) IF CHANGES HAVE OCCU RRED WITHIN THE BUSI NESS ENTITY SINCE TH E TIME YOU WERE LICENSED YOU ARE NOT ELIGIBLE TO PARTICIPATE IN THE FAST TRACK APPLICATION PROCESS. ANY CHANGES TO THE CURRENTLY LICENSED LOCATION SUCH AS THE ADDING OR DROPPING SPACE OR ADDING MOTOR VEHICLE FUEL PUMPS OR DRIVE-UP WINDOWS WITHOUT THE SALE OF ALCOHOLIC BEVERAGES WILL DISQUALIFY YOU FROM PARTICIPATING IN THE FAST TRACK APPLICATION PROCESS AT THIS TIME. Have you been cited and found responsible for any violations within the last 12 months? ___Yes* ___No (*If yes, you are not eligible to participate in the Fast Track Application process at this time) Do you have any pending violations? ___Yes* ___No (*If yes, you are not eligible to participate in the Fast Track Application process at this time) Have you had any criminal convictions since you were last licensed? ___Yes * ___No (*If yes, you are not eligible to participate in the Fast Track Application process at this time) LC-1135a (Rev. 04/11) American LegalNet, Inc. www.FormsWorkFlow.com COMPLETE THE INFORMATION PERTAINING TO YOUR APPLICATION: Transfer of Ownership of: ___ SDD ___ SDM ___ Resort SDD with the existing permits and/or permissions: WARNING -THE MICHIGAN LIQUOR CONTROL CODE OF 1998 PROVIDES AS FOLLOWS: Section 1003 of the Michigan Liquor Control Code of 1998, Being MCL 436.2001 provides as follows: "A person who makes a false statement to the commission, orally or in writing, for the purpose of inducing the commission to act or refrain from taking action or for the purpose of enabling or assisting a person to evade the provisions of this act is guilty of a violation of this act . . . " I understand that the MLCC will rely on each and every answer in this application and that any false statements on this application or to the MLCC's representatives may result in the denial of this application or revocation of the license. Applicant (Buyer) Signature(s): _______________________________________________________________ Home Address (street, city, zip code): ___________________________________________________________ Home Telephone: ( ) __________________________________________________________________ Name of Contact Person: ____________________________________________________________________ Telephone number of Contact Person: ( )____________________________________________________ You may mail this form to the MLCC Licensing Divi sion at the address on the top of the form or you may FAX this form to the MLCC Licensing Division at 517-322-6137. AUTHORITY: MAC R436.1103 COMPLETION: Mandatory PENALTY: No license or permit issued 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