STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 713-7235 Website: http://www.ct.gov/dcp APPLICATION FOR TRANSFER OF INTEREST Backer:________________________________________Phone #:_______________________ Permittee:____________________________________________________________________ Business Address:______________________________________________________________ Permit #:________________________TOTAL PERCENTAGE IN LLC __________________ NAME OF PRESENT INTEREST HOLDERS IN LLC: PROPOSED MEMBERS & TOTAL INTEREST HELD: Please indicate below if any of the proposed members/shareholders now hold a permit from this Department as a permittee or backer, including partner or stockholder (other than applicant). NAMES OF MEMBERS TOTAL INTEREST HELD DO ANY NEW LLC MEMBERS HOLD AN INTEREST IN ANY OTHER PERMIT PREMISES? YES NO If YES, PLEASE GIVE PERMIT NUMBER:_____________________________________ Requested by:_________________________________________________________________ (Name) _________________________ (Date) _________________________________________________________________________________________________ (Street Address) (Town) (State) (Zip Code) _________________________________________________________________ (Phone Number) American LegalNet, Inc. www.FormsWorkflow.com