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Application For Salesperson License LC MW 843 - Michigan
| Application For Salesperson License Form. This is a Michigan form and can be used in General Licensing Liquor Control Commission Statewide . |
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Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 Toll Free (866) 813-0011 · www.michigan.gov/lcc License #: Date Issued: (For MLCC use only) Application for Salesperson License For the period May 1, 2011 to April 30, 2014 (Authorized by R 436.1853) Instructions: · · To be considered for a license, you must complete this application and return it with a $35.00 license fee to the address at the top of this form. Please make all checks or money orders payable to the State of Michigan. A Salesperson license only applies to a person who sells, promotes, delivers, or otherwise assists in the sale of alcoholic liquors in the State of Michigan. You must notify this Commission when you have a change in employment and licenses may be transferred at no charge. (This license is not required for a Driver-Helper, as defined in administrative rule R 436.1001(1)(h). Part 1 - Applicant Information Check Type of License: 1. Name of applicant: 2. Street Address: 3. City: 4. Telephone Number: 6. Date of Birth: 8. Have you ever been arrested? No Yes State: 5. E-mail Address: 7. Driver's License No: If yes, complete the additional page attached to this form . Zip Code: New License $35.00 Transfer license (no fee) (Which license number is being transferred?) 9. Do you hold, have a financial interest in, or are you currently employed by a retail liquor licensee in the State of Michigan? If yes, please list below: 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 submitting false or incomplete information is cause for denial of the license and is a violation of the Liquor Control Code pursuant to MCL 436.2003. Date Print Name and Title Signature Part 2 - To be completed by the company employing the salesperson. 10. Name of Company: 11. Street Address: 12. City: 13. Telephone Number: 15. Federal Identification Number: 16. I request the Michigan Liquor Control Commission to grant a Salesperson license to: to be employed in the following capacity (check all that apply): Driver Delivery State: 14. E-mail address: Zip Code: Promotion Date Print Name and Title Signature LC-MW-0843 (Rev 12/12) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 Toll Free (866) 813-0011 · www.michigan.gov/lcc License #: Date Issued: (For MLCC use only) Supplemental Questions to Part 1 (8) 1. Full name on LC-MW-0843 Form: 2. Date of the offense(s): 3. City and state or county and state where the offense(s) occurred: 4. The specific charge(s) (DUI, assault, forgery, robbery, etc.) AND the level of the charge (either a misdemeanor of felony). 5. Disposition of the charge(s). This may include but is not limited to the following: a. Any fines imposed; b. Any class or workshop to be attended; c. Any jail time served; d. If applicable, the terms of probation (including evidence and dates of successful conclusion of the probation); e. Any other court conditions (such as registration as a sex offender) 6. Statement regarding the conditions the court placed on the individual. Date Signature LC-MW-0843 (Rev 12/12) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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