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 WITHIN A LIMITED LIABILITY COMPANY Backer Entity Name:____________________________________________________________ Phone #:____________________________ E-Mail:___________________________________ Permittee Name:_______________________________________________________________ Business Address:______________________________________________________________ Trade Name:_____________________________________Permit #:______________________ PRESENT MEMBERS & TOTAL INTEREST HELD: NAMES OF MEMBERS TOTAL INTEREST HELD PROPOSED MEMBERS & TOTAL INTEREST HELD: NAMES OF MEMBERS TOTAL INTEREST HELD DO ANY NEW LLC MEMBERS HOLD AN INTEREST IN ANY OTHER PERMIT PREMISES? YES NO If YES, Please Provide PERMIT NUMBER: _____________________________ Then provide proposed member’s name and indicate whether he/she is a permittee or backer on the permit. **Attach a separate sheet with this information I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of Backer (Transferee): X ________________________________________________________________ Date: __________________________ Print Name Clearly: X_________________________________________________________________ Date: __________________________ American LegalNet, Inc. www.FormsWorkFlow.com