Form Lc Mw 0843 – Fill Out and Use This PDF

	Michigan Department of Licensing and Regulatory Affairs	License #:
	Liquor Control Commission (MLCC)
		Date Issued:
	7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505
	Toll Free (866) 813-0011 • www.michigan.gov/lcc		(For MLCC use only)

Application for Salesperson License

For the period May 1, 2014 to April 30, 2017

(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:

New License $35.00

Transfer license (no fee) (Which license number is being transferred?)

1.Name of applicant:

2.Street Address:

3.	City:			State:	Zip Code:
4. Telephone Number:				5. E-mail Address:
6.	Date of Birth:			7. Driver's License No:
8. Have you ever been arrested?		No	Yes If yes, complete the additional page attached to this form .

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:	State:	Zip Code:
13. Telephone Number:	14. E-mail address:

15.Federal Identification Number:

16.I request the Michigan Liquor Control Commission to grant a Salesperson license to:

Driver Delivery Promotion

Date

Print Name and Title

Signature

LC-MW-0843 (Rev 03/14) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

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	Michigan Department of Licensing and Regulatory Affairs	License #:
	Liquor Control Commission (MLCC)
		Date Issued:
	7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505
	Toll Free (866) 813-0011 • www.michigan.gov/lcc		(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 03/14) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

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