LOSINST Rev 8/18 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Email: dcp.licenseservices@ct.gov Website: www.ct.gov/dcp Instructions for Completing the Application for Out-of-State Shipper222s Permit Enclosed is the application for an Out-of-State Shipper222s Permit allowing the sale of alcoholic liquor, beer or wine. Please note the following when filing the application: Applicant 226 The name of the permittee is the applicant for the liquor permit. This is the individual who operates/manages an establishment holding a liquor permit. The permittee may, in some cases, also be the owner/backer of the business that holds the permit. Backer 226 An individual or legal business entity that owns the business to which the liquor permit is issued. In the event that you must attach additional sheets of explanation for certain items on the application, additional sheets should be identified with the first and last name of the permittee, the name of the business and the city in which the business will operate. Home State Permit 226 Every application for an out-of-state shipper222s permit shall be accompanied by a photostatic copy or by other documentary evidence of a permit or license issued by the state in which the applicant derives authority to manufacture, sell or distribute alcoholic liquors. Federal Basic Permit 226 Every application for an out-of-state shipper222s permit shall be accompanied by a photostatic copy of the federal basic permit. Out of State Winery Shipper222s Permit 226 To apply for an out-of-state winery shipper222s permit, you must be the manufacturer of the product. If you import product, you must apply for an out-of-state shipper permit for alcoholic liquor/wine. Out-of-state winery applicants shall furnish an affidavit affirming that the out-of-state winery did not produce more than one hundred thousand gallons of wine during the most recent calendar year, in order to be eligible to ship directly to retailers. Fees & Form of Payment 226 The application must be accompanied by the application filing fee and the appropriate initial permit fee. Please refer to the chart below for the appropriate fee. Checks or money orders should be made payable to 223Treasurer, State of Connecticut.224 The application filing fee is not refundable. Type of Permit Application Filing Fee Initial Permit Fee Total Fee Due Out-of-State Shipper222s Permit for Alcoholic Liquor/Wine $100.00 + $1250.00 = $1350.00 *Connecticut Out-of-State Shipper222s Permit for Alcoholic Liquor/Wine $100.00 + $ 90.00 = $ 190.00 Out-of-State Shipper222s Permit for Beer $100.00 + $1250.00 = $1350.00 *Connecticut Out-of-State Shipper222s Permit for Beer $100.00 + $ 90.00 = $ 190.00 Out-of-State Winery Shipper222s Permit for Wine only $100.00 + $ 315.00 = $ 415.00 *Only Connecticut Wholesalers or an applicant for a Connecticut Wholesaler permit may apply for a Connecticut Out-of-State Shipper permit Return the completed application, appropriate documentation and fee to: Department of Consumer Protection License Services Division 450 Columbus Blvd, Ste. 801 Hartford, CT 06103 American LegalNet, Inc. www.FormsWorkFlow.com LOS-01, Rev DEPARTMENT OF CONSUMER PROTECTION Email: Website: INSTRUCTIONS: All spaces must be completed - please print in ink or type. A check or money order for the appropriate fee must accompany this application made payable to 223Treasurer, State of Connecticut.224 374 City State Zip Code Telephone Number (w/ area code) Date of Birth Social Security Number Email Address Have you, or any member of your family, either as permittee or backer ever been refused a permit or had a permit revoked by the Liquor Control Division? Yes No If yes, please attach name(s) and date(s) on a separate sheet of paper. Jurat for Applicant I affirm, under penalty of false statement, that my statements and answers to all questions in this application are true and complete. Signature of Applicant (Permittee) Date Subscribed and sworn to before me, this day of 20Notary Seal Signed: (Commissioner of Superior Court/Notary Public/Justice of the Peace My Commission Expires Name of Backer (The legal entity that owns the business) Business Street Address City State Zip Code Telephone Number (w/ area code) FEIN or Social Security Number Email Address IndicateOrganizational Structure: Sole Proprietor Corporation Limited Liability Company (LLC) Limited Liability Partnership (LLP) Partnership If a corporation, please indicate date of incorporation and state where incorporated. If not a Connecticut corporation, please indicate the date of authorization to conduct business in the State of Connecticut. Have you or any of your employees or agents loaned any money or extended any credit in any form for a period in excess of thirty (30) days, directly or indirectly, to any person, firm or organization holding a permit for the sale of alcoholic liquor in the State of Connecticut? Yes No If yes, please attach on a separate sheet of paper, the names of permittees and the amounts of credit given. Have you, or any member of your family, either as permittee or backer ever been refused a permit or had a permit revoked by the Liquor Control Division? Yes No If yes, please attach name(s) and date(s) on a separate sheet of paper. For Official Use Only American LegalNet, Inc. www.FormsWorkFlow.com For Corporation, LLC, LLP or Partnership (Attach additional sheet if necessary) List the names, titles and signatures of all persons associated in the ownership. Name Title Signature Name Title Signature Name Title Signature Name Title Signature Jurat for Backer (Individual) I affirm, under penalty of false statement, that my statements and answers to all questions in this application are true and complete. Signature of Backer (Individual) Date Subscribed and sworn to before me, this day of 20 Notary Seal Signed: (Commissioner of Superior Court/Notary Public/Justice of the Peace My Commission Expires Jurat for Backer (For a Corporation, LLC, LLP and Partnership) F CORPORATION, LLC OR LLP Signature of duly authorized officer with title; or PARTNERSHIP, signature of partners I affirm, under penalty of false statement, that my statements and answers to all questions in this application are true and complete. Signature of Backer & Title Date Signature of Backer & Title Date Subscribed and sworn to before me, this day of 20 Notary Seal Signed: (Commissioner of Superior Court/Notary Public/Justice of the Peace My Commission Expires [ American LegalNet, Inc. www.FormsWorkFlow.com