FOR OFFICIAL USE ONLY DCPLC-HotelGuestBar Rev 3/17 STATE OF CONNECTICUT Telephone: (860) 713-6210 Email: dcp.liquorcontrol@ct.gov Website: www.ct.gov/dcp/liquorcontrol DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION \ Instructions: Complete this application and submit with a check or money order made payable to "Treasurer, State of Connecticut" for the total number of hotel guest bar(s) for which you are requesting approval at $100.00 each. Return APPLICATION FOR HOTEL GUEST BAR(S) the completed application and appropriate fee to: Department of Consumer Protection 450 Columbus Blvd., Suite 801 Hartford, CT 06103 Permittee Name (First Name, Middle Initial, Last Name) Name of Business(Trade Name) Business Street Address (Location of Business) City Business Telephone Number (with area code) Backer's Name Liquor Permit Number State Business Fax Number (with area code) Zip code Number of Hotel Guest Bar(s) requested @ $100.00 each Bars are lockable from desk? Bars have key/card locking device? Yes Yes No No I UNDERSTAND THAT THESE BARS ARE ONLY TO BE AVAILABLE TO GUESTS FROM: 9:00AM TO 1:00AM ­ MONDAY through THURSDAY 9:00AM TO 2:00AM ­ FRIDAY and SATURDAY 11:00AM TO 1:00AM ­ SUNDAY **NO KEY/CARD WILL BE GIVEN TO A BAR WHERE THE PERSON RENTING IS UNDER 21 YEARS OF AGE.** I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of permittee, backer or authorized representative of the backer: X ________________________________________________________________ Date: __________________________ Subscribed and affirmed before me: Signed X__________________________________________________________ (Commissioner of Superior Court, Notary Public, Justice of Peace) Date __________________________ American LegalNet, Inc. www.FormsWorkFlow.com