Print Form 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 # ____________ Business ID # ___________ PARTICIPATION PERMIT APPLICATION [Authorized by MCL 436.1523, R 436.1041, and R 436.1105] 1. Name of Applicant for Participation Permit: _________________________________________________________ (Individual, Limited Partnership, Corporation, Limited Liability Company ) Name of Current Licensee: _______________________________________________________________ Address of Licensed Establishment: ________________________________________________________ 2. Participation Permit applicants who are limited partnerships, corporations, or limited liability companies (LLC) must attach the following executed application forms: 1) LC-687 for each general partner of a limited partnership or general partnership, a corporation, an LLC or an individual 2) LC-621 for each stockholder or member with 10% interest or more of a corporation or LLC 3) LC-38 for each limited partner and each stockholder or member who has under 10% interest of a limited partnership, corporation or LLC. 4) LC-52 for corporate applicants; LC-52a for LLC applicants; LC-52b for Partnerships 5) Copy of Partnership Agreement with Certificate of Limited Partnership* for limited partnerships, Articles of Incorporation* for corporations, and Articles of Organization* for LLC's. *If entity is not incorporated/organized in the State of Michigan* 3. Will you be required to or have you invested any funds for the permit requested? If yes, attach executed Summary of Finances Statement (LC-1125) Is there an agreement to facilitate this request? Yes No* If Yes, Agreement Enclosed: Lease Agreement Franchise Agreement Other * Yes No Management Agreement *(Explain) ______________________________________________________________________ R 436.1041(3) provides in pertinent part as follows: ". . .Upon written request of the licensee, the commission may issue a participation permit to a licensee who meets all of the following qualifications: (a) The non-licensed person who receives use or benefit from the licensee's license or who receives gross or net profits from a licensed business shall meet the same qualifications as a licensee as prescribed by R 436.1101 ET SEQ. (b) The licensee makes application and either cancels an existing participation permit or receives a new participation permit before adding or deleting any participating non-licensed person. . ." I understand that the falsification of the information on this form, or any false statements made during the application process, may constitute grounds for denial of this application or revocation of the permit issued. ________________________________________________________________________________________ Signature of Applicant for Participation Permit Date ________________________________________________________________________ Authorized Signature of Licensee LC-1124 (Rev 04/11) AUTHORITY: R 436.1041 COMPLETION: Mandatory PENALTY: No License and/or Permit Date 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