License Information Change

License Information Change

Use this form to submit changes pertaining to your license(s).

Name of Licensee*

Street Address of Licensed Business*

Business License Number(s)*

What kind of information are you providing?*

Select all that apply.

Change in Ownership Structure

Change in Social Equity Criteria

Change of Licensee's Representative or Contact person

Change of Name

Change of Mailing Address, Phone or Email

Something Else

Description of Changes*

Please briefly describe the changes being made.

Licensee Attestations*

By checking this box, I acknowledge the following:

a. If this application is being completed on behalf of an organized legal entity, Licensee will upload a copy of a government issued ID for each person identified, to include, the name, home address, telephone number, and email address of direct and indirect owners, directors, members, managers, officers, partners, shareholders, and the registered agent, and the entity’s bylaws, operating agreement, or other organizational documents indicating the ownership structure;

b. Licensee acknowledges the City may investigate the income and property tax status of the Licensee, its direct or indirect owners, directors, officers, members, managers, partners, shareholders, employees, and any medical marijuana facilities or adult-use marijuana establishments related to any of the aforementioned individuals, and that any outstanding taxes, fines, or fees will be paid prior to requested changes being approved;

c. Licensee acknowledges the Detroit Police Department may perform criminal background checks on all individuals identified as direct or indirect owners of the Licensee, as well as review the violation history at the licensed premises; and

d. Licensee attests that to its knowledge all of the information provided in this form is true and accurate, and is aware that the provision of false, misleading, or fraudulent information is cause for non-renewal, suspension, or revocation of the license.

Upload Relevant Documents

Please provide the written documentation related to this change, which could include a new assumed name certificate, a membership transfer agreement, tax clearances for new members, or a CRA amendment application and approval. Additional documents may be requested.

Drag and drop files here or

Licensee Contact Information*

Please provide an email address for a contact person:

First and last name of contact person:*

Send me a copy of my responses

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