Print Form Michigan Department of Licensing and Regulatory Affairs FOR MLCC USE ONLY MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 Request ID # INDIVIDUAL STOCKHOLDER, LIMITED LIABILITY MEMBER OR CORPORATE STOCKHOLDER QUESTIONNAIRE Business ID # [Authorized byMCL436.1916 and R 436.1403] General Instructions: Completion of this form is required to be considered for a license. All Applicants must complete Part 1 and Part 2. Individual stockholders / members must also complete Part 3. Corporate stockholders must also complete part 4. Sign the completed form in ink and return it to the MLCC address above. PART 1. Applicant Corporation / Limited Liability Company Identification Full name of Corporation / Limited Company: Business Street Address: City or Village: State: Zip Code: County: PART 2. Stockholder / Member Identification – all stockholders/members (individual or corporate). Name of Individual, Corporate Stockholder or Limited Liability Company Member: Street Address: City or Village: State: Home Telephone No. ( Zip Code: ) Business Telephone No. ( ) I am, or will be, the owner of the following shares of stock in this Corporation or % of membership interest, if any (include, joint ownership, trusteeships, etc.) Number of Shares or % of Membership Membership Interest Common or Preferred Other Names on these Share or Membership Interest PART 3. Individual Stockholders / Members complete this section: Sex: F M Date of Birth Are you a U. S. Citizen? Yes Place of Birth No Social Security No Are you a Naturalized Citizen? OR If you are not a U. S. Citizen, are you a registered alien? OR, If you are not a registered alien, do you have a Visa? Have you ever legally changed your name? Yes No Yes Yes No Yes No Number Alien Reg. Number No If so please list TYPE: If Yes, from to If you have ever been known by any other names list them here: Full Name of Spouse If Spouse is known by any other names list them here: American LegalNet, Inc. www.FormsWorkFlow.com Spouse Date of Birth Spouse Place of Birth Do you or your spouse hold any law enforcement powers, including powers of arrest? Yes No If Yes, please explain: Do you or your spouse hold interest in any manufacturer and/or wholesaler license? Yes No If Yes, please explain: I or my spouse previously held, or now hold, interest in the following licenses for sale of alcoholic beverages as sole licensee, partner, or stockholder / member: Name of Licensee Type of License Location Date 1. 2. 3. Attach additional sheet if necessary List your former employers for the past three years: Dates Occupation Employer Name and Address 1. 2. 3. Attach additional sheet if necessary PART 4. Corporate Stockholders / Limited Liability Company Members – Complete this section: Corporation/LLC Name: Incorp./Organization Date: State of Incorp./Organization: Michigan Authorization Date: Resident Agent Name, Address, Telephone No. : Check one of each: Profit or Non-Profit Corporation and Public or Private Corporation Date last annual report / statement filed with Michigan Corporation & Securities: Corporate Officers: NAME ADDRESS PHONE NUMBER President Vice-President Secretary Treasurer Number of Shares Authorized: Common Preferred Number of Shares Issued: Common Preferred Person (s) authorized to sign the application on behalf of the corporate stockholder or limited liability company member: THE COMMISSION WARNS ALL APPLICANTS FOR LICENSES NOT TO INVEST ANY MONEY OR TO COMMIT THEMSELVES TO ANY BINDING AGREEMENTS IN THE EXPECTATION OF BEING ISSUED A LICENSE FOR SALE OF ALCOHOLIC BEVERAGES UNTIL OFFICIALLY NOTIFIED BY THE MLCC THAT THEIR APPLICATION HAS BEEN APPROVED. American LegalNet, Inc. www.FormsWorkFlow.com WARNING! Section 436.2003 of the Liquor Control Code provides: “A person who makes a false or fraudulent 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 any person to evade the provisions of this act is guilty of a violation of this act and is punishable in the manner provided for in section 909.” Further, the rules and regulations of the Commission entitled “General Rules” provide: “A licensee shall not obtain a license for the use or benefit of another person whose name does not appear on the license nor shall a licensee allow a person whose name does not appear on the license to use or benefit from the license,” and, “A licensee shall not sell or transfer an interest in a business licensed by the Commission without the prior written approval of the Commission.” I hereby swear that I have read all of the above answers and that they are true and that I have read and understand the warnings. Date of Application Signature of Applicant Name of person completing this form if not applicant LC-621 (Rev. 04/11) Authority: MAC R 436.1103 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