Request For Waiver Of Statute Or Licensing Qualifications
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Request For Waiver Of Statute Or Licensing Qualifications Form. This is a Michigan form and can be use in Liquor Control Commission Statewide.
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Tags: Request For Waiver Of Statute Or Licensing Qualifications, LC 1865, Michigan Statewide, Liquor Control Commission
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Request ID# ______________
Michigan Department of Licensing and Regulatory Affairs
LIQUOR CONTROL COMMISSION
7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505
REQUEST FOR WAIVER OF STATUTE OR LICENSING QUALIFICATIONS
Instructions:
Complete this form to request a waiver of statute or licensing qualifications. Be specific in the
provisions you are asking the Commission to waive.
Applicant or Licensee Names:
Address of Location to be
Licensed or Licensed Address:
Types of Licenses requested:
Enter Statute or Rule number you
are requesting to be waived:
Enter the Statute or Rule number
which allows the Commission to
consider a waiver for this request:
The undersigned applicant or licensee requests a waiver for the following reasons:
Date Signed:
Applicant/Licensee Signature:
Applicant/Licensee Signature:
Applicant/Licensee Signature:
Applicant/Licensee Signature:
LC-1865 (Rev. 04/11)
AUTHORITY: PA 58 of 1998
COMPLETION: Mandatory
PENALTY: No waiver granted
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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