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Limited Partners Stockholders Or Members Statement Form. This is a Michigan form and can be use in Liquor Control Commission Statewide.
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Tags: Limited Partners Stockholders Or Members Statement, LC 38, Michigan Statewide, Liquor Control Commission
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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.
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