Print Form Michigan Department of Labor & Economic Growth FOR MLCC USE ONLY MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 Release No: ____________ RELEASE OF ALCOHOL OR ALCOHOLIC BEVERAGES FOR COMMERCIAL USE [Authorized by MAC R 436.1809(5)] _________________________________________________________________________________________________ GENERAL INSTRUCTIONS • • • • Michigan businesses which use alcohol or alcoholic beverages for commercial purposes are required to complete and submit this form for each purchase of alcohol or alcoholic beverages. Failure to obtain the written Certificate of Release from the MLCC is a violation of the rules and regulations of MLCC. Complete the required information and sign the form. Mail the completed and signed from to the address at the top of this form. MAKE A COPY OF THIS APPLICATION FOR YOUR FILE. The MLCC will return a copy of the Certificate of Release to the BUYER and to the SELLER of Alcohol. Sellers of Alcohol may NOT ship alcohol or alcoholic beverages to the BUYER until they receive the copy of the executed Certificate of Release. A copy of the Certificate of Release MUST be sent with the shipment. 1. NAME AND ADDRESS OF BUYER 2. NAME AND ADDRESS OF SELLER BUYER'S MICHIGAN LICENSE OR PERMIT NUMBER SELLER'S MICHIGAN LICENSE NUMBER 3. TYPE AND USE OF ALCOHOL CHECK THE APPROPRIATE BOX AND COMPLETE THE DESCRIPTION (IF REQUIRED) A. Check type of Alcohol Used: B. Check Commercial Use Ethyl Alcohol Medicines / Drugs / Pharmaceuticals Distilled Spirits / Blending Whiskeys Scientific Wine Blending or Rectifying Alcoholic Beverages Other (describe): Chemicals Flavoring Extracts Other (describe): 4. QUANTITY OF ALCOHOL OR ALCOHOLIC BEVERAGES Date to be shipped Quantity (size, pack, case, etc.) Wine Gallons 5. MOTOR OR RAIL CARRIER USED FOR SHIPMENT Proof Gallons 6. SIGNATURE OF BUYER DATE CERTIFICATE OF RELEASE The release of the type and quantity of alcohol or alcoholic beverages for the use as described in #3 and #4 above is granted. __________________________________ LC-MW-836 (Rev. 10/2007) Authority: MAC R 436.1809 (5) Completion: Mandatory Penalty: No License ___________ Manufacturers and Wholesalers Section Date The Department of 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