For Official Use Only LIS-01, REV 9/09 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6200 Email: liquor.control@ct.gov Website: www.ct.gov/dcp APPLICATION FOR LIQUOR WHOLESALER SALESMAN CERTIFICATE INSTRUCTIONS: You must file an application for certificate not later than ten (10) days after the date of initial employment. If you change employers, you must refile with the Department of Consumer Protection within ten (10) days. The individual applying for the certificate must complete this form. All spaces must be completed – please print or type. This application must be accompanied by a non -refundable fee in the amount of $50.00, made payable to “Trea surer, State of Connecticut” and returned to: Department o f Co nsumer Pro tec tio n, Lic ense Servic es Divisio n, 165 Capito l Avenue, Hartfo rd, CT 06106 Applicant’s Name (First Name, Middle Initial, Last Name) Applicant’s Street Address Social Security Number City or Town State Date of Birth Zip Code Telephone Number (with area code) Are you a minor or a person who holds a position that would prohibit you from obtaining a liquor permit? (See CT General Statutes Section 30-45 for a list of such individuals) Yes No Have you been convicted of a felony crime or an alcohol related motor vehicle violation? Yes No If yes, attach a statement including the date(s) and nature of conviction(s), the court(s) where the case(s) were disposed of and a description of the circumstances. Wholesaler Employer Name Date Hired Street Address City or Town State Zip Code I CERTIFY UNDER PENALTY OF LAW THAT THE ABOVE PROVIDED INFORMATION IN THIS APPLICATION IS THE TRUTH TO THE BEST OF MY KNOWLEDGE ______________________________________________________ Signature of Applicant (Employee) ____________________ Date Subscribed and sworn to before me Notary Seal ______________________________________________________ Signature of Notary Public ___________________ Date ______________________________________________________ Signature of Employer (Officer or Authorized Agent) ____________________ Date Subscribed and sworn to before me ______________________________________________________ Signature of Notary Public Notary Seal ___________________ Date American LegalNet, Inc. www.FormsWorkFlow.com