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 LIMITED PARTNERS, STOCKHOLDERS OR MEMBERS STATEMENT [Authorized by MCL 436.1523 and MAC 436.1105(a)] I, _______________________ A Stockholder A Limited Partner A Member Name of: ________________________________________________________________________________________ Home Address Make the following statements to the Michigan Liquor Control Commission in connection with the application of: ___________________________________________________________________________________________ Print Name of Limited Partnership OR Corporation for a new or transfer of ________________________________________________________________________ Type of License From: ______________________________________________________________________________________ If Transfer, Name of Seller Located at __________________________________________________________________________________ Address of License Have you ever been convicted of a criminal offense, including alcohol related infractions ____ Yes If yes, place charge and disposition on the back of this form. ____ No Do you or your spouse hold any position, either by appointment or election, which involves the duty to enforce any penal law of the United States of America, or the penal laws of the State of Michigan, or any penal ordinance or resolution of any municipal subdivisions of the State of Michigan (civil defense volunteer policeman, mayors, village presidents, and members of city councils are not considered to be law enforcement officers). _____ Yes _____ No Do you or your spouse hold any class of license for the manufacture or sale of alcoholic beverages at wholesale in Michigan, or any interest (stockholder / member) in any class of license for the sale of alcoholic liquor in Michigan _____ Yes _____ No which would be in conflict with the granting of this license? I state that I am of legal age (21) for consumption of alcoholic beverages in the State of Michigan. My date of birth is _______________________________. I understand that the falsification of the information on this form, or any false statements made during investigations, may constitute grounds for denial or revocation of the licenses issued. ___________________________________________ Signature of Applicant Date LC-38 Rev. 04/11 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