Michigan Department of Licensing and Regulatory AffairsLiquor Control Commission (MLCC) Toll-Free: 866-813-0011 - www.michigan.gov/lcc Business ID: Request ID:(For MLCC Use Only)For information on manufacturer and wholesaler licenses and permits, including a checklist of required documents for a completed application, please visit the Liquor Control Commission's frequently asked questions website by clicking this link .Part 1 - Licensee Information Individuals, please state your legal name. Corporations or Limited Liability Companies, please state your name as it is filed with the State of Michigan Corporation Division.Licensee name(s):Address:City:Zip Code: LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LCC-351 (11-16)Delivery Vehicle Decal Application Contact Name:Email:Phone: Part 2 - Additional Vehicle Decal(s) Requested Number of delivery vehicle decals requested:Part 5 - Signature of Licensee I certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I agree to comply with all requirements of the Michigan Liquor Control Code and Administrative Rules. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.2003. Date Signature of Licensee Print Name of Licensee & TitlePlease return this completed form along with fees, if applicable, to: Michigan Liquor Control Commission Mailing address: P.O. Box 30005, Lansing, MI 48909 Hand deliveries or overnight packages: Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Fax to: 517-284-8557 X $50.00 fee per vehicle decal = Total Due: Make check payable to State of Michigan***Wholesaler licensees are granted one (1) delivery vehicle decal with their license, but must register and pay for additional delivery vehicle decals*** ***Micro Brewer licensees must register and pay for all delivery vehicle decals***Part 3 - Replacement Vehicle Decal(s) Requested List decal number(s) to be replaced: There is no charge for a replacement decal. The decal(s) listed will be terminated and the licensee must destroy the physical decal(s) no longer used. Part 4 - Vehicle Decal(s) No Longer Used and Not Being ReplacedList decal number(s) that will no longer be used and not be replaced: The decal(s) listed will be terminated and the licensee must destroy the physical decal(s) no longer used. I certify that the decals in Part 3 and/or Part 4 have been lost or destroyed. New and/or Replacement Decal Numbers (MLCC Use Only) Micro Brewer licensee (MLCC Fee Code 4038) Wholesaler licensee (MLCC Fee Code 4085)Decal(s) requested for: American LegalNet, Inc. www.FormsWorkFlow.com Credit Card Authorization FormMichigan Department of Licensing and Regulatory Affairs Finance and Administrative Services Revenue Services Name: Card Number: Security Code/CVV Code: Address: City: State: Zip Code: Phone: Payment is for: Applicant/Licensee Name: Request or Business ID #: Transaction Amount: Discover MasterCard VisaCheck One: Signature * * FAX COMPLETED FORM TO SECURE FAX LINE: 517-284-8557 * * * * DO NOT EMAIL OR MAIL THIS FORM * * Requests with credit card payments that are not faxed to the above secure fax line will be destroyed along with the credit card authorization in order to ensure the security of applicants222 personal credit card numbers. * *IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED* *LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LCC-300 (02-18)IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED. Credit Card Payment Itemization: Special License Fee(s): Sunday Sales Permit (AM): Sunday Sales Permit (PM): Catering Permit: New Add Bar Transfer Add Bar: License Renewal Fee(s): New Retailer License(s): Manufacturer License(s): Transfer Retailer License(s): Temporary Authorization Fee: Inspection Fee(s): Fee AmountMLCC Fee Code40364008403740044038401240344033403240314012/4034Fee Type4085 Wholesaler License(s): LARA Revenue Services is not a part of the Michigan Liquor Control Commission (MLCC). Receipt of payment and application forms by LARA Revenue Services does not constitute receipt of an applicationby the MLCC. Applications submitted through LARA Revenue Services may take up to two (2) additional business days to be received by the MLCC after receipt by LARA Revenue Services. For requests that require a timely receipt of an application by the MLCC to be processed, such as Special Licenses and temporary requests, please ensure that your application will be received in adequate time to be processed by the MLCC after the payment is received and processed by LARA Revenue Services. LARA Revenue Services is not a part of the Michigan Liquor Control Commission (see note below). Conditional License 4012 Expiration Date: American LegalNet, Inc. www.FormsWorkFlow.com