Participating Agrement Participation Permit Application {LCC-205}

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)Participating Agreement / Participation Permit ApplicationFor information on licenses and permits, please visit the Liquor Control Commission's frequently asked questions website by clicking this link.Part 2 - Non-Licensed Participant Information If participant is a corporation or limited liability company, state name exactly as it was filed with the Michigan Corporations Division, and submit a copy of the Articles of Incorporation, Articles of Organization, or Certificate of Authority to Conduct Business in Michigan filed with the Corporations Division.Address:City:Zip Code: Non-licensed participant name:Mailing address:City:Zip Code: 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. %Email: Phone:Contact name: 2.What is the commencement date of the agreement? 3.What is the duration of the agreement?Part 4 - Signature of Applicant or Licensee Licensees shall be held responsible for all actions and conduct of the operation of the licensed establishment and the actions of the non-licensed participant in the conduct of the licensed business. The licensee shall not transfer these responsibilities to any individual or organization. Failure to uphold this responsibility may result in a violation, suspension , or revocation of the license. 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. Date Signature of Applicant or Licensee Name of Applicant or Licensee/TitleLCC-205 (02-16)Applicant/Licensee name(s):Part 1 - Applicant/Licensee Information Individuals, please state your legal name. Corporations or Limited Liability Companies, please state your name as it is filed with the State of Michigan Corporation Division.1.What percentage of the gross sales or net profits of the licensed business will the non-licensedparticipant receive under the agreement? Good cause statement, pursuant to administrative rule R 436.1041. $70.00 Inspection Fee - Not required if part of a request for a new license or transfer of an existing license. (MLCC Fee Code 4036) Copy of participating agreement.Part 3 - Required Fee and Documents (Authorized under R 436.1041) American LegalNet, Inc. www.FormsWorkFlow.com Part 5a - Specific Information on Non-Licensed Participant Each individual that will be a non-licensed participant must complete Part 5a, 5b, and 5c. If the participant is a corporation or limited liability company, complete Part 5a and 5c for the participant AND a separate copy of Part 5a, 5b and 5c for each stockholder/member of the participant entity.Name:Address:City:Zip Code:Contact name:Phone:Email: State:Have you ever been licensed by the Michigan Liquor Control Commission (MLCC) or do you currently hold an interest in any other licenses issued by the MLCC? Yes NoPage 2 of 2LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Date Signature of Participant Name of Participant/TitlePart 5c - Signature of Participant I authorize the MLCC to run an Internet Criminal History Access Tool (ICHAT) and Secretary of State (SOS) check prior to docketing your request for Commission review. 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.Please return this completed form along with corresponding fee and documents 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: 517-284-8557LCC-205 (02-16) Individual Corporation Limited Liability Company Stockholder Member Date of Birth:Social Security Number:Driver's License Number:Are you a citizen of the United States of America?Is your spouse a citizen of the United States of America?Have you ever legally changed your name?If you answered "yes", please list your prior name(s) (including maiden):Spouse's full name (if currently married):Spouse's date of birth:Do you or your spouse hold any position, either by appointment or election, which involves the duty to enforce 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 NoDoes your spouse hold a retail, manufacturer, or wholesaler license issued by the MLCC?Have you ever been found guilty, pled guilty, or pled no contest to a criminal charge or any local ordinance violations? If Yes, list below (attach additional pages if necessary):DispositionHas your spouse ever been found guilty, pled guilty, or pled no contest to a criminal charge or any local ordinance violations? If Yes, list below (attach additional pages if necessary): Yes NoDateCity/StateChargeDisposition Yes NoChargeCity/StateDatePart 5b - Personal Information (Individuals) Yes No Yes No No Yes Yes No 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: Security Code/CVV Code: 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: 517-284-8557 * * * * 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 (02-18)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