Form LCC-300 "Credit Card Authorization Form" - Michigan

What Is Form LCC-300?

This is a legal form that was released by the Michigan Department of Licensing and Regulatory Affairs - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Michigan Department of Licensing and Regulatory Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LCC-300 by clicking the link below or browse more documents and templates provided by the Michigan Department of Licensing and Regulatory Affairs.

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Download Form LCC-300 "Credit Card Authorization Form" - Michigan

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Michigan Department of Licensing and Regulatory Affairs
LARA Revenue Services is not a part of
Finance and Administrative Services
the Michigan Liquor Control
Revenue Services
Commission (see note below).
Credit Card Authorization Form
* * 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 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 on Card:
Payment Amount:
Billing Address:
Card Number:
City:
State:
Zip Code:
Check One:
MasterCard
Visa
Discover
Phone:
Email:
Security Code/CVV Code:
Applicant/Licensee Name:
Request or Business ID #:
Expiration Date:
Payment is for:
Signature
IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS
LARA Revenue Services is not a part of the Michigan Liquor Control
CREDIT
CARD
AUTHORIZATION,
YOU
MUST
PROVIDE
AN
Commission (MLCC). Receipt of payment and application forms by
ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING
LARA Revenue Services does not constitute receipt of an application
PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED.
by the MLCC. Applications submitted through LARA Revenue
Credit Card Payment Itemization:
Services may take up to two (2) additional business days to be
MLCC
received by the MLCC after receipt by LARA Revenue Services.
Fee Type
Fee Amount
Fee Code
Inspection Fee(s):
4036
For requests that require a timely receipt of an application by the
MLCC to be processed, such as Special Licenses and temporary
Special License Fee(s):
4008
requests, please ensure that your application will be received in
adequate time to be processed by the MLCC after the payment is
Temporary Authorization Fee:
4037
received and processed by LARA Revenue Services.
License Renewal Fee(s):
4004
Manufacturer License(s):
4038
Wholesaler License(s):
4085
New Retailer License(s):
4012
Transfer Retailer License(s):
4034
Conditional License
4012
New Add Bar
Transfer Add Bar:
4012/4034
Sunday Sales Permit (AM):
4033
Sunday Sales Permit (PM):
4032
Catering Permit:
4031
LCC-300 (10-20)
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
Michigan Department of Licensing and Regulatory Affairs
LARA Revenue Services is not a part of
Finance and Administrative Services
the Michigan Liquor Control
Revenue Services
Commission (see note below).
Credit Card Authorization Form
* * 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 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 on Card:
Payment Amount:
Billing Address:
Card Number:
City:
State:
Zip Code:
Check One:
MasterCard
Visa
Discover
Phone:
Email:
Security Code/CVV Code:
Applicant/Licensee Name:
Request or Business ID #:
Expiration Date:
Payment is for:
Signature
IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS
LARA Revenue Services is not a part of the Michigan Liquor Control
CREDIT
CARD
AUTHORIZATION,
YOU
MUST
PROVIDE
AN
Commission (MLCC). Receipt of payment and application forms by
ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING
LARA Revenue Services does not constitute receipt of an application
PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED.
by the MLCC. Applications submitted through LARA Revenue
Credit Card Payment Itemization:
Services may take up to two (2) additional business days to be
MLCC
received by the MLCC after receipt by LARA Revenue Services.
Fee Type
Fee Amount
Fee Code
Inspection Fee(s):
4036
For requests that require a timely receipt of an application by the
MLCC to be processed, such as Special Licenses and temporary
Special License Fee(s):
4008
requests, please ensure that your application will be received in
adequate time to be processed by the MLCC after the payment is
Temporary Authorization Fee:
4037
received and processed by LARA Revenue Services.
License Renewal Fee(s):
4004
Manufacturer License(s):
4038
Wholesaler License(s):
4085
New Retailer License(s):
4012
Transfer Retailer License(s):
4034
Conditional License
4012
New Add Bar
Transfer Add Bar:
4012/4034
Sunday Sales Permit (AM):
4033
Sunday Sales Permit (PM):
4032
Catering Permit:
4031
LCC-300 (10-20)
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.