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Affidavit For Substitute Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
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Tags: Affidavit For Substitute, Connecticut Statewide, Department Of Consumer Protection
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
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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
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