DCPLC-Pers Hist Rev 12/12 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6210 Email: liquor.control@ct.gov Website: www.ct.gov/dcp All spaces must be completed ­ please print or type. This statement must be completed by the permittee and each person who is a backer member or partner for this liquor permit. Please attach a separate sheet if necessary. A. PERSONAL/BUSINESS INFORMATION: Last Name First Name Middle Name AUTHORIZATION FOR RELEASE OF FINANCIAL INFORMATION & STATEMENT OF PERSONAL HISTORY Business Title Relationship to Liquor Permit Backer City or Town: % Interest / # of Shares Aliases, Other names known by, Maiden name State: Zip Code: Permittee Residence Street Address (no P.O. Boxes): Telephone Number (Home): Telephone Number (Cell): Fax Number: E-mail Address: Motor Vehicle Driver's License Number State of Issue: Sex: Male Female Date of Birth Place of Birth Are you a US Citizen? If No, Alien Reg Number: Date & Place of Naturalization B. EMPLOYMENT OF PUBLIC OFFICES: Please indicate below any public offices held by the applicant, individual backers, shareholders, corporate officers, LLC members, etc. *Please attach a separate sheet if necessary Name Title Place Town, City, State or Federal Agency If NONE, check here NONE NO YES C. CRIMINAL HISTORY: Have you had any prior felony convictions? (If YES, please complete the "CHRO-Review of Criminal Convictions Worksheet" ) D. AUTHORIZATION: 1. I authorize any agent from the State of Connecticut, Department of Consumer Protection to obtain any information related to me from criminal justice agencies, past or present employers, financial or lending institutions, credit bureaus, consumer reporting agencies and retail business establishments or individuals. This information may include, but is not limited to, my residential, personal, and criminal history records and financial and credit information. 2. I authorize criminal justice agencies to release records concerning my criminal history to the Department of Consumer Protection for the purpose of determining my suitability, as a permittee or backer; or 1. I agree that no individual or entity shall be held liable for use of this authorization to determine my suitability as a permittee or backer I certify, under penalty of law that the information provided in this statement is the truth to the best of my knowledge. ______________________________________________ / ________________________________________ / _________________ Signature of Applicant, Permittee, Backer, Backer Print Name Date Member or Partner completing this statement American LegalNet, Inc. www.FormsWorkFlow.com