Print Form Michigan Department of Licensing and Regulatory Affairs LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 INITIAL APPLICATION MLCC USE ONLY - DO NOT WRITE IN THIS SPACE COMPLETE ALL INFORMATION IN THIS SECTION: Name: ______________________________________________________________________________________ (of individual, Partnership, Corporation or Limited Liability Company - if transferring ownership, indicate SELLER'S name) DBA: (assumed name of business): _______________________________________________________________ Business Phone:( ) _____________ Type of License: ________________ License Number: ______________ Business Address (number and street): ____________________________________________________________ City or Village ____________________ *Township _______________ County ____________ Zip Code ________ * You must indicate Township if business is located outside of City or Village limits. COMPLETE ONLY INFORMATION PERTAINING TO YOUR REQUEST: Applicant for NEW License (check type of license desired): ___ SDD ___ SDM ___ Tavern ___ Class C ___ B-Hotel ___ Resort B-Hotel ___ Resort SDD ___ Resort C ___ Club ___ Wholesale ___ Other: _________________________ Transfer of Ownership: (Name of BUYER): ____________________________________________________ If Corporation, list proposed stockholders: _____________________________________________________ __________________________________________________________________________________________ Transfer of Location to: (Address) ____________________________________________________________ (City or Village, Township, County, Zip Code) ___________________________________________________ • A property document must be attached - lease, option to lease, purchase agreement of option to purchase, land contract or warranty deed for the proposed location. Transfer of Classification from ______________________________ to _______________________________ Self Incorporation (Name of Corporation) _______________________________________________________ Transfer of Stock; transfer of membership or assignment of membership interest (explain transaction below): Add Partner (Name of person being added): ____________________________________________________ Drop Partner (Name of person being dropped): __________________________________________________ PERMITS (check all that apply): ___ Dance Only ___ Entertainment Only ___ Dance-Entertainment ___ Food ___ Sunday Sales ___ Topless Activity ___ Bowling ___ Concourse ___ Golf ___ Outdoor Service ___ Living Quarters ___ Direct Connection ___ Add Bar ___ Misc. - specify use (I.E. ski, racquetball, etc.) _________________________________ LC-1135 (Rev. 04/11) 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 COMPLETE ONLY INFORMATION PERTAINING TO YOUR REQUEST: Add Space (address or explanation) __________________________________________________________ Drop Space (address or explanation) _________________________________________________________ Rebuild (address or explanation) ____________________________________________________________ CORPORATIONS Include a list of all stockholders, their home addresses, home and business phone numbers and birth dates. LIMITED LIABILITY COMPANIES Include a list of all members, managers and assignees of membership, their home addresses, home and business phone numbers and birth dates. PARTNERSHIPS LIMITED PARTNERSHIPS Include a list of all partners, their home addresses, home and business phone numbers and birth dates. Include a list of general partners and limited partners, their home addresses, home and business phone numbers. General partners must also submit birth dates. Licensee Signature(s): _______________________________________________________________ Home Address (street, city, zip code): _____________________________________________________ Home Phone: ( ) _________________________ Applicant Signature(s): _______________________________________________________________ Home Address (street, city, zip code): _____________________________________________________ Home Phone: ( ) _________________________ SPACE FOR CORPORATION - LLC - PARTNERSHIPS - LIMITED PARTNERSHIPS MEMBER INFO. Attach additional sheets if necessary You may mail or FAX this form to MLCC LICENSING at 517-322-6137. American LegalNet, Inc. www.FormsWorkFlow.com