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Application For Broker License LC MW 843C - Michigan
| Application For Broker 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 No. Date Issued (For MLCC use only) Application for Broker License For the period May 1, 2011 to April 30, 2014 (Authorized by MAC 436.1853) General Instructions · A Broker License only applies to a company who represents a Vendor of Spirits, Brewer, Wine Maker, Outstate Seller of Beer, Wine, or Mixed Spirit Drink, or a Wholesaler licensed by the Commission where the company is to act as the Michigan broker to aid and assist the supplier in the sale, delivery or promotion of alcoholic liquor. · To be considered for a Broker License you must complete this application, sign the form and submit the following documents: 1. A copy of the current Articles of Incorporation/Organization with Operating Agreement, if applicable. 2. Report of Stockholders-Members-Partners (Form LCC-3010). 3. A copy of the Broker Agreement executed between the broker and the company they represent. 4. $35.00 license fee. Return the application to the address at the top of this form with a check made payable to the State of Michigan. · A broker must notify the MLCC when the relationship with the Vendor of Spirits, Brewer, Wine Maker, Outstate Seller of Beer, Wine, or Mixed Spirit Drink or a Wholesaler is terminated. · Failure to obtain a required license is a violation of the Liquor Control Code. Submitting false or incomplete information is also a violation. Violation of the Code may result in denial, suspensions, or revocation of the license and a fine. · Make a copy of this application for your file. Part 1 - Applicant Information (check type of request) Name of Limited Liability Company or Corporation: Address: Contact person for broker: Phone Number: Has the MLCC previously issued a license to this Company? Yes New license $35.00 License transfer (no fee) E-mail: No If yes, please list the type of license, the year issued and the license number (attach additional pages, if needed): Has the company ever been denied a license or had a license revoked by the MLCC? If yes, please list facts, dates and places on a separate sheet. 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. Signature: Date: Yes No Part 2 - To be completed by Company to be represented by Broker Name of Company: Address: Phone Number: I request the MLCC grant a broker license to: Signature: CASHIER VALIDATION (do not write in this space) Federal ID Number: Title: Date: LC-MW-0843C (Rev 12/2012) 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 Page 1
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