STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 713-7235 Website: http://www.ct.gov/dcp APPLICATION FOR TRANSFER OF STOCK WITHIN A CORPORATION or PARTNERSHIP CHANGE Backer Entity Name:____________________________________________________________ Phone #:____________________________ E-Mail:___________________________________ Permittee Name:_______________________________________________________________ Business Address:______________________________________________________________ Trade Name:_____________________________________Permit #:______________________ PRESENT STOCK OR PARTNERSHIP SET UP: NAMES OF SHAREHOLDERS OR PARTNERS AMOUNT OF STOCK OR % OF PARTNERSHIP HELD PROPOSED STOCK OR PARTNERSHIP SET UP: **Please indicate any new issued shares or partners NAMES OF SHAREHOLDERS OR PARTNERS AMOUNT OF STOCK OR % OF PARTNERSHIP HELD DO ANY NEW SHARESHOLDERS OR PARTNERS HOLD SHARES OR PARTNERSHIP IN ANY OTHER PERMIT PREMISES? YES NO If YES, Please Provide PERMIT NUMBER: _____________________________ Then provide proposed member’s name and indicate whether he/she is a permittee or backer on the permit. **Attach a separate sheet with this information I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of Backer Entity (New Shareholder or Partner): X ________________________________________________________________ Date: __________________________ Print Name Clearly: X_________________________________________________________________ Date: __________________________ American LegalNet, Inc. www.FormsWorkFlow.com