Hospital Liquor Permit Application {LCC-252}

Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Toll-Free: 866-813-0011 - www.michigan.gov/lcc Business ID: Request ID: (For MLCC Use Only) Hospital Liquor Permit Application For more information on manufacturer and wholesaler licenses and permits, please visit the Liquor Control Commission's frequently asked questions website by clicking this link. Part 1 - Applicant Information Name of hospital: Address: City: City/township/village where permit will be issued: Zip Code: County: Phone: Email: Contact Name: Part 2 - Required Documents & Information 1. Attach a copy of the hospital license issued by the appropriate Michigan licensing agency. List the expiration date of the hospital license (if not indicated on attached license copy): 2. Number of hospital beds: 3. Estimated annual amount of alcoholic liquor to be ordered from MLCC (750ml bottles): Part 3 - Applicant Signature The spirits over 21% alcohol by volume purchased by the hospital under this permit will be used for medicinal purposes only on the prescription or order of a licensed physician. The spirits will not be used in making medicines. 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 Name & Title Signature of Applicant Date Please return this completed form along with corresponding 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: 517-763-0059 American LegalNet, Inc. www.FormsWorkFlow.com LCC-252 (02-16) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.