Michigan Department of Energy, Labor & Economic Growth MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 INTERNET RENEWAL AUTHORIZATION [Authority: MCL 436.1501] Instructions and Fill-In Application Form Please read these instructions carefully to avoid having your application returned to you due to missing or deficient information. Contact the MLCC Renewal Unit toll free at 1-866-813-0011 if you have any questions or need assistance. Please use the APPLICATION FOR INTERNET RENEWAL AUTHORIZATION form (below) when applying for a personal Identification Number. Make sure that you: 1. Submit your application by mail only to: Department of Energy, Labor & Economic Growth, Liquor Control Commission,PO Box 30005,Lansing,Michigan48909 2. Under section 1 select one box. 3. Complete Licensee Name, License number, Business ID, Licensed Business Address as shown on liquor license and a contact telephone number. Use home office information if you have multiple licensed businesses under same name. 4. Obtain all appropriate signatures-remember that only authorized signors (as indicated on your LC-52, LC-52a, or LC-52b, Report of Officers, Directors, Stockholders and General Partners of a Limited Partnership) may sign the application. If additional signatures are necessary-attach a sheet including remaining signatures. Note: We must receive form with original signatures. Stamped signatures are not acceptable. 5. Please read important disclaimer information below licensee signature. The Internet Renewal Authorization will remain in effect until amended or cancelled. 6. Additional instructions including payment information may be found on our website at: https:// www2.dleg.state.mi.us/mlcc from March 1 through June 15. it is not necessary to obtain a Personal Identification Number to view these instructions. APPLICATION FOR INTERNET RENEWAL AUTHORIZATION FORM LC-0017 (Rev. 01/09) Authority: MCL 436.1107 Penalty: No on-line renewal The Department of Energy, Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkflow.com Michigan Department of Energy, Labor & Economic Growth FOR MLCC USE ONLY MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 INTERNET RENEWAL AUTHORIZATION Business ID # or Master ID# [Authority: MCL 436.1501] Instructions: ♦Please print or type entries. ♦Carefully read and complete the entire authorization form. ♦If you have multiple licensed businesses under the same name you should use one application to authorize Internet renewal for all locations. ♦Mail the completed form to: MichiganLiquor Control Commission,7150 Harris Drive, P.O. Box 30005,Lansing,MI 48909 ♦If you have any questions about completing this form please call toll free 1-866-813-0011 and ask for the Renewal Unit. 1. Type of application (select only one) NEW - Select if establishing authorization to allow on-line Internet renewal. CANCEL - Select if you want to cancel the authorization to renew on-line. Licensees may cancel this authorization by completing and mailing this form to the address above. 2. Licensee name (as shown on liquor license) 3. *License # 4. *Business I.D# 5. *Licensed Business Address: 6. *Telephone Number *If multiple licensed businesses under same name use home office information. Authorization I authorize the State of Michigan, Michigan Liquor Control Commission (MLCC) to accept the Internet Renewal for the above business(es) in lieu of Annual Renewal Application(s). All licensees must sign and enter their address below, including ALL co-licensees, partners and all general partners of limited partnerships. The application for authorization for Internet renewal must be signed by an authorized corporate officer or an authorized member or manager of the L.L.C. and indicate the office held. Authorized signature must be a person authorized to sign any and all documents required by the Michigan Liquor Control Commission under Commission Rules. Stamped signatures are not acceptable. Please enclose documentation if ownership has changed. Licensee’s Signature Print Licensee’s Name Licensee’s Home Address Licensee’s Signature Print Licensee’s Name Licensee’s Home Address Licensee’s Signature Print Licensee’s Name Licensee’s Home Address Licensee’s Signature Print Licensee’s Name *If additional signatures are necessary – attach a sheet including remaining signatures. Licensee’s Home Address By signing this form, licensees certify they are the sole owners of the licensed business(es) and agree to abide by all provisions of the Liquor Control Code and rules. A Personal Identification Number (PIN) will be assigned and forwarded to the licensee mailing address upon approval by the MLCC. The Internet Renewal Authorization will remain in effect until a new form is submitted to cancel or amend the authorization. The licensees understand that submitting false or incomplete information is cause for denial of the issuance or renewal of the license(s) and is a violation of the Liquor Control Code. NOTE: LICENSEE'S ARE RESPONSIBLE FOR THE SECURITY OF THEIR PIN NUMBER. ANYTHING DONE UNDER THE USER NUMBER AND PIN NUMBER IS RECORDED AS BEING DONE BY YOU. YOU ARE ACCOUNTABLE FOR ANY ACTIONS TAKEN BY OTHERS WHO HAVE OBTAINED YOUR PERSONAL IDENTIFICATION NUMBER (PIN). LC-0017 (Rev. 01/09) Authority: MCL 436.1107 Penalty: No on-line renewal The Department of Energy, Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkflow.com