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Consumer Complaint Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
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Tags: Consumer Complaint, Connecticut Statewide, Department Of Consumer Protection
CONSUMER COMPLAINT
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR CONTROL DIVISION
165 Capitol Avenue · Hartford, CT 06106
E-Mail: liquor.control@po.state.ct.us
Fax Number: (860) 713-7235
Agent Number: (860) 713-6210
WHAT IS YOUR NAME?
WHAT IS YOUR HOME ADDRESS?
STREET ADDRESS
CITY
WHAT IS YOUR DAYTIME TELEPHONE
NUMBER (INCLUDING AREA CODE)?
WHAT IS YOUR EVENING TELEPHONE NUMBER
(INCLUDING AREA CODE)?
E-MAIL ADDRESS:
STATE
ZIP CODE
MY COMPLAINT INVOLVES THE FOLLOWING LICENSED LIQUOR ESTABLISHMENT:
NAME OF BUSINESS
STREET ADDRESS
CITY
NATURE OF COMPLAINT:
• SALE TO MINOR(S)
• SALE TO INTOXICATED PATRONS
• REFILLING
• AFTER HOURS
• PURCHASE FOR RESALE
• UNLAWFUL GAMBLING
• PERFORMER CONDUCT
• OTHER ACTIVITY (EXPLAIN)
PERMIT NUMBER, IF KNOWN
CHECK ALL THAT APPLY:
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PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE (SPECIFIC DATES, DAYS OR NIGHTS, INDIVIDUAL(S)
INVOLVED, BRAND NAMES, WITNESSES, VICTIMS, ETC.): ______________________________
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SIGNATURE
DATE
Attach as many additional pages as needed to complete your complaint.
Note: All complaints are public information. By submitting this complaint, you give the Department of Consumer Protection
your permission to release a copy of the Consumer Complaint.
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