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 REPORT OF CORPORATE OFFICERS, BOARD OF DIRECTORS & STOCKHOLDERS [Authorized by MCL 436.1529(1) and MAC R 436.1051] GENERAL INSTRUCTIONS •The provisions of MCL 436.1529(1) prohibit the transfer of more than 10% of the stock interest of a licensed corporation without the prior consent of the MLCC. A person that owns or acquires 10% or more interest in a privately held corporation shall submit fingerprints. •This report is part of the license application and must be completed by an officer of the corporation who is authorized to sign and execute documents. •PUBLIC CORPORATIONS: Complete sections 1-5 and 7-9 and sign the CERTIFICATION on page 2 of this form. •PRIVATELY HELD CORPORATIONS Complete sections 1-9 and sign the CERTIFICATION on page 2 of this form. : 1. Name and registered address of corporation 2. Type of license 3. State in which Articles of Incorporation filed 4. Date authorized to do business in Michigan or date Articles of Incorporation filed with Michigan 5. Check type of corporation: Corporation Division. Privately held (not traded on stock exchange) Publicly traded 6. Stockholder Information [This section must be completed by all privately held corporations] NAME AND ADDRESS OF STOCKHOLDERS STOCK DATE CERTIFICATE NO. NO. OF SHARES ISSUED 1. 2. 3. 4. 5. 6. 7. 8. If more listings are needed please attach an additional page showing the same information. (continued) American LegalNet, Inc. www.FormsWorkFlow.com 7. CORPORATE OFFICERS NAME AND ADDRESS President Vice President Secretary Treasurer Asst. Secretary 8. BOARD OF DIRECTORS Chairperson NAME AND ADDRESS Vice-Chairperson Secretary Director Director 9. NAME AND ADDRESS OF DESIGNATED PERSONS AUTHORIZED TO CONDUCT BUSINESS, SIGN THE APPLICATION AND ANY DOCUMENTS REQUIRED BY THE MLCC. NOTE: STOCKHOLDERS & OFFICERS LISTED ON THIS FORM ARE CONSIDERED AUTHORIZED UNLESS EXPRESSLY EXCLUDED IN A WRITTEN AGREEMENT EXECUTED BY ALL STOCKHOLDERS THAT MUST BE PROVIDED TO THIS OFFICE. PLEASE INDICATE OTHER DESIGNEEES ONLY WARNING: The Liquor Control Code of 1998 provides as follows in Section 1003, being MCL 436.2003 “. . . A person who makes a false or fraudulent statement to the commission, orally or in writing, for the purpose of Inducing the commission to act or refrain from taking action or for the purpose of enabling or assisting a person to evade the provisions of this act is guilty of a violation of this act and is punishable in the manner provided for in Section 909. . .” I, certify that the information contained in this report and any attachments are complete, true, and taken from the records of this Corporation and that I understand the WARNING above. SIGNATURE: PRINT NAME: DATE: POSITION: LC-52 (Rev. 04/11) Authority: MCL 436.1529(1) and MAC R 436.1051 Completion: Mandatory Penalty: No License 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