Substitute Permittee Application rev. 2/10 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Division - State Office Building - Hartford, Connecticut 06106 IF ALL ITEMS ARE NOT COMPLETED THIS FORM WILL BE RETURNED READ THIS BEFORE FILLING OUT Fill in EVERY ITEM. Failure to do so may cause return of application and delay in processing. Application must be signed and SWORN TO by the substitute permittee and a backer in the presence of a Notary Public, Justice of the Peace, or Commissioner of the Superior Court. _____________________________________________________________________________________________________________________________________________ FEES An application to substitute the permittee permanently (over eight weeks), must be accompanied with a fee of $30.00 in the form of a certified check, money order, or bank check. ALL FEES ARE NON-REFUNDABLE (G.S.545-Sec. 30-62). If you hold more than one liquor permit, a $30.00 fee must be submitted for each. Make checks payable to “Department of Consumer Protection”. 1. Backers’ Name (Individual, Partnership, LTD. Partnership, Corp. Owner of LLC) 2. Permit Number _____________________________________________________________________________________________________________________________________________ 3. Address of Permit Business 4. Trade Name _____________________________________________________________________________________________________________________________________________ 5. Permittee’s Name (Out going) 6. Business Telephone Number AFFIDAVIT FOR SUBSTITUTE _____________________________________________________________________________________________________________________________________________ 7. Name of substitute (incoming) 8. Social Security Number 9. Age 10. Sex _____________________________________________________________________________________________________________________________________________ 11. Place of birth (City, State or County) 12. Date of Birth 13. Resident Address of Substitute and Home Telephone Number _____________________________________________________________________________________________________________________________________________ 14. Substitute’s Resident address for last three years _____________________________________________________________________________________________________________________________________________ 15. Beginning date of substitution Ending date of substitution (date outgoing permittee quit, was terminated or changed position) (If this is a permanent substitution, fill in the word “permanent”) QUESTION YES NO EXPLANATION _____________________________________________________________________________________________________________________________________________ 16. Have you ever been convicted of any violation of a Federal or State law, If so, list all particulars, give date, charge, town and disposition. including motor vehicle violations. Include any pending charges, nolles entered within thirteen months of the date you sign this form, and/or matters in which you were granted accelerated rehabilitation, youth offenders status, or alcohol education program that have not yet been disposed of? _____________________________________________________________________________________________________________________________________________ 17. Have you ever forfeited a bond to appear in any court to answer any charge If so, name the court, and when forfeited. for the violation of any Federal or State law concerning alcoholic liquor? _____________________________________________________________________________________________________________________________________________ 18. Are you a sheriff, deputy sheriff, constable, judge, police officer, first If so, which position? selectman or hold a public office? _____________________________________________________________________________________________________________________________________________ 19. Has any member of your family or household including anyone with whom If so, state name and date. you have cohabited with in the past five years ever been refused a permit by the Department of Liquor Control or the Department of Consumer Protection or forfeited a permit granted by either? _____________________________________________________________________________________________________________________________________________ 20. Do you now hold a permit from this Department or its predecessor as a If so, state kind of permit and address of premises. permittee or backer including partner or stockholder (other than this application)? _____________________________________________________________________________________________________________________________________________ 21. Have you ever held a permit from this Department or the Department of If so, state class of permit and year(s) held. Liquor Control? _____________________________________________________________________________________________________________________________________________ 22. Have you ever applied for and been refused a permit by this Department or If so, state kind of permit and date of application. the Department of Liquor Control? _____________________________________________________________________________________________________________________________________________ 23. Have you ever forfeited, by revocation, a permit granted to you by this If so, state kind of permit and date of revocation. Department or the Department of Liquor Control? _____________________________________________________________________________________________________________________________________________ 24. Will you draw a commission on alcoholic beverage? If so, explain commission. OTHER SIDE MUST BE COMPLETED American LegalNet, Inc. www.FormsWorkFlow.com YES NO ________________ 25. If you are not the owner, has the backer designated in this application appointed you as manager or other principal representative on the premises described in the application, and vested in you the full authority and control of said premises and the conduct of all permit business thereon? _____________________________________________________________________________________________________________________________________________ 26. Have you borrowed money or received credit in any form for a period in excess of thirty (30) days, directly or indirectly, from any manufacturer permittee of alcoholic liquors or backer thereof, or from any wholesaler permittee of alcoholic liquors or backer thereof, or from any member of the family of such manufacturer permittee or backer thereof, or from any stockholder in a corporation manufacturing or wholesaling alcoholic liquor? _____________________________________________________________________________________________________________________________________________ If you are the owner: 27. The applicant hereby accepts appointment as manager or principal representative on the premises described in the application, and has accepted the authority and control of said premises and the conduct of all business therein relative to the sale of alcoholic liquor. _____________________________________________________________________________________________________________________________________________ 28. Are you able to read and understand English? _____________________________________________________________________________________________________________________________________________ 29. Date of Application 30. Signed (Substitute) _____________________________________________________________________________________________________________________________________________ 31. Personally appeared signer of the foregoing statement who represented (Notary Public, Justice of the Peace, Comm. of Superior Court) Date that he is duly authorized to sign on behalf of said organization and who has satisfied me of his identity and made oath before me to the truth of the matters contained therein. FOR PARTNERS OR INDIVIDUAL BACKER 32. The backer hereby appoints the above named applicant as manager or principal representative on the premises described in the application wherein the sale of alcoholic liquor is to be permitted and has vested in said applicant the full authority and control of such premises and has vested in said applicant the full authority and control of such premises and of the conduct of all business therein relative to the sale of alcoholic liquor. 33. Personally appeared the signer of foregoing statement who satisfied me of his identity and made oath before me to the truth of the matters contained therein. Signed: (Backer-Individual, Partner, G.P.) (Notary Public, Justice of the Peace, Commissioner of Superior Court) Date _____________________________________________________________________________________________________________________________________________ 34. Personally appeared the signer of the foregoing Signed: (Backer-Individual) (Notary Public, Justice of the Peace,) Date statement who satisfied me of his identity and made oath before Commissioner of Superior Court) me to the truth of the matters contained therein. _____________________________________________________________________________________________________________________________________________ 35. Personally appeared the signer of the foregoing Signed: (Backer-Individual) (Notary Public, Justice of the Peace, Date statement who satisfied me of his identity and made oath before Commissioner of Superior Court) me to the truth of the matters contained therein. _____________________________________________________________________________________________________________________________________________ 36. Personally appeared the signer of the foregoing Signed: (Backer-Individual) (Notary Public, Justice of the Peace Date statement who satisfied me of his identity and made oath before Commissioner of Superior Court) me to the truth of the matters contained therein. FOR BACKER IF CORPORATION OR UNINCORPORATED ASSOCIATION OR LLC Personally appeared the signer who satisfied me of his identity and represented that he is duly authorized to sign in behalf of said corporation: that the statements contained in his answers to the foregoing questions are true. _____________________________________________________________________________________________________________________________________________ 37. Signed (officer of backer corporation or unincorporated association, llc member) Title Name of corporation of unincorporated association _____________________________________________________________________________________________________________________________________________ STATE Date Notary Public, Justice of the Peace, Comm. of Superior Court American LegalNet, Inc. www.FormsWorkFlow.com