Credit Card Authorization Form {LCC-300}

Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Toll-Free: 866-813-0011 - www.michigan.gov/lcc Credit Card Authorization Form * * FAX COMPLETED FORM TO SECURE FAX LINE: 517-373-4202 * * * * 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 applicants' 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* * Name: Address: City: Check One: State: Zip Code: Phone: Applicant/Licensee Name: Request or Business ID #: Transaction Amount: Card Number: MasterCard Expiration Date: Visa Discover Payment is for: Signature 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: Fee Type Fee Amount MLCC Fee Code 4036 4008 4037 4004 4038 4085 4012 4034 4012/4034 4033 4032 4031 4011 American LegalNet, Inc. www.FormsWorkFlow.com Inspection Fee(s): Special License Fee(s): Temporary Authorization Fee: License Renewal Fee(s): Manufacturer License(s): Wholesaler License(s): New Retailer License(s): Transfer Retailer License(s): New Add Bar Transfer Add Bar: Sunday Sales Permit (AM): Sunday Sales Permit (PM): Catering Permit: Secondary Location Permit: LCC-300 (02-17) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.