Age Statement Form
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Age Statement Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
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Tags: Age Statement Form, Connecticut Statewide, Department Of Consumer Protection
AGE STATEMENT FORM
Permittee / Agent:
Date:
20
I
(Please Print Name)
hereby represent to
,a
(Permittee / Agent Name)
Permittee of the Connecticut Department of Consumer Protection that I am over the age
of 21 years, having been born on
19
at
(Month / Day)
(Town / State)
This statement is made to induce said permittee to sell or otherwise furnish alcoholic
beverages to the undersigned. I understand that Title 30 of the Connecticut General
Statutes prohibits the sale of alcoholic liquor to any person who is not twenty-one years
of age.
I understand that I am subject to a fine of one hundred dollars for the first offense
and not more than two hundred fifty dollars for each subsequent offense for
willfully misrepresenting my age for the purposes set forth in this statement.
C.G.S. 30-89
(Signature)
TO BE COMPLETED BY PERMITEE OR AGENT:
NAME:
ADDRESS:
ID TYPE:
ID NUMBER:
Photo ID
YES
NO
Optional
2ND Form of ID
ID TYPE:
ID NUMBER:
Photo ID
YES
NO
DCP 8/04
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