CPLTR-01, NEW 1/06 For Official Use Only 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 Transporter's Liquor Permit INSTRUCTIONS: All spaces must be completed - please print in ink or type. A check or money order in the amount of $1100.00 must accompany this application and should be made payable to "Treasurer, State of Connecticut." Applicant Name of Shipper Permittee (First Name, Middle Initial, Last Name) Street Address Telephone Number (w/ area code) Date of Birth City Social Security Number Email Address State Zip Code / / 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 Notary Seal Subscribed and sworn to before me , this __________ day of ______________________________ 20_________ ___________________________________________________________________ Signed: (Commissioner of Superior Court/Notary Public/Justice of the Peace _______________________ My Commission Expires Backer Name of Backer (The owner or proprietor of the business) Business Street Address Telephone Number (w/ area code) Indicate Organizational 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. American LegalNet, Inc. www.FormsWorkflow.com City FEIN or Social Security Number Email Address State Zip Code 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 Name Name Name Title Title Title Title Signature Signature Signature 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 Notary Seal Subscribed and sworn to before me, this __________ day of ______________________________ 20_________ ___________________________________________________________________ Signed: (Commissioner of Superior Court/Notary Public/Justice of the Peace _______________________ My Commission Expires Jurat for Backer (For a Corporation, LLC, LLP and Partnership) FOR CORPORATION, LLC OR LLP Signature of duly authorized officer with title; For 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 Instructions for completing the Application for Transporter's Liquor Permit: 1) Applicant - 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. 2) Backer ­ An individual or legal business entity that owns the business to which the liquor permit is issued. 3) Fee & Form of Payment - The application must be accompanied by the filing fee of $100.00 and the initial permit fee of $1000.00. A check or money order in the amount of $1100.00 should be made payable to "Treasurer, State of Connecticut." The application filing fee is non -refundable. 4) ICC Permit - A photostatic copy of your ICC Permit must accompany the application. [ Return the completed application and fee to: + License Services Division Department of Consumer Protection 165 Capitol Avenue Hartford, CT 06106 American LegalNet, Inc. www.FormsWorkflow.com