FOR OFFICIAL USE ONLY DCPLC-ACB Rev 11/09 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: liquor.control@ct.gov Website: www.ct.gov/dcp APPLICATION FOR ADDITIONAL CONSUMER BAR(S) Instructions: Complete this application and submit with a check or money order made payable to “Treasurer, State of Connecticut” for the total number of additional consumers bar(s) for which you are requesting approval at $190.00 each. Return the completed application and appropriate fee to: License Services Division Department of Consumer Protection 165 Capitol Avenue Hartford, CT 06106 Permittee Name (First Name, Middle Initial, Last Name) Liquor Permit Number Name of Business Business Street Address (Location of Business) City State Zip code Business Telephone Number (with area code) Business Fax Number (with area code) Backer’s Name (LLC, INC, SOLE PROP.) Number of additional consumer bar(s) requested @ $190.00 each NOTE: This application must be accompanied by an 8.5 x 11 inch sketch of the entire premises, showing the location(s) of the additional consumer bar(s) for which you are requesting approval. You must also submit a photograph(s) of these proposed location(s). I have attached a sketch and photograph(s), as described above, related to the additional consumer bar(s) for which I am requesting approval Yes No Signature of duly authorized representative Date American LegalNet, Inc. www.FormsWorkFlow.com