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)Vendor Representative License ApplicationPart 1 - Applicant Information Applicant legal name:Home address:City:State: Zip Code:City:Zip Code:Phone:Birthdate:Email Driver's License Number:Page 1 of 2LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 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 .1.Have you ever been found guilty, pled guilty, or pled no contest to a criminal charge or any localordinance violations? If Yes, list below (attach additional pages if necessary): Yes NoDateCity/StateCharge (also indicate Felony or Misdemeanor)Disposition (Fine, Jail Time, Probation) Part 2 - License Fee & Required Documents License Transfer, no fee - New License, $50.00 - Make check payable to State of Michigan (MLCC Fee Code 4038)List the license number to be transferred:Part 3 - Applicant QuestionsLC-MW-0843a (01-17) If not currently licensed, a copy of Michigan State Police ICHAT report for the applicant, or similar report from your state of residence, if not a Michigan resident. Visit the MSP ICHAT website to obtain an ICHAT report: https://apps.michigan.gov/ichat/home.aspx. Your application will not be considered if you do not submit an ICHAT or similar report from another state. Registered office address:State: 2.Do you or your spouse hold any position, either by appointment or election, which involves the duty toenforce any penal law of the United States of America, or the penal laws of the State of Michigan, or any penal ordinance or resolution of any municipal subdivisions of the State of Michigan? Yes No3.Do you or your spouse hold interest in a retail, manufacturer, or wholesaler license issued by the MLCC? Yes No Yes No4.Are you currently employed by a retail liquor licensee in the State of Michigan? If Yes on question 2, 3, or 4, please explain: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Part 4 - Signature of Applicant (Vendor Representative) 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. Print Applicant Name Applicant Signature DatePart 5 - Information on Vendor of Spirits Employing Applicant (to be completed by employing company)Part 6 - Authorized Signature for Company Employing Applicant The company requests the MLCC to grant a Vendor Representative License to the applicant. 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. Company name:Address:Phone:Email Contact Name:Phone:Email: Federal Employer Identification Number (FEIN): Date Authorized Signer for Company Print Name and TitlePlease return this completed form along with corresponding documents and fees 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: 517-373-4202State: Zip Code:City:LC-MW-0843a (01-17) 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: Expiration Date: 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: 517-373-4202 * * * * 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 (06-17)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 American LegalNet, Inc. www.FormsWorkFlow.com