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 STOCK CHANGE IN LIMITED LIABILITY COMPANY MEMBERS OR CHANGE IN PARTNERS WITHIN A LIMITED PARTNERSHIP Backer:________________________________________Phone #:_______________________ Permittee:____________________________________________________________________ Business Address:______________________________________________________________ Permit #:________________________________Issue Date:____________________________ PRESENT MEMBERSHIP OF STOCK SET UP: Amount of Shares Issued:___________ NAMES OF MEMBERS/SHAREHOLDERS AMOUNT OF STOCK HELD PROPOSED MEMBERSHIP OR STOCK SET UP: Amount of Shares Issued:_________ 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/SHAREHOLDERS AMOUNT OF STOCK HELD Requested by:_________________________________________________________________ (Name) _________________________ (Date) _________________________________________________________________________________________________ (Street Address) (Town) (State) (Zip Code) _________________________________________________________________ (Phone Number) American LegalNet, Inc. www.FormsWorkflow.com