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Request For Waiver Of Statute Or Licensing Qualifications LC 1865 - Michigan

Request For Waiver Of Statute Or Licensing Qualifications Form. This is a Michigan form and can be used in General Licensing Liquor Control Commission Statewide .
 Fillable pdf Last Modified 7/29/2011
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Print Form 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. American LegalNet, Inc. www.FormsWorkFlow.com
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