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: □ □ □ □ □ □ □ □ ___________________________________________________________ ___________________________________________________________ PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE (SPECIFIC DATES, DAYS OR NIGHTS, INDIVIDUAL(S) INVOLVED, BRAND NAMES, WITNESSES, VICTIMS, ETC.): ______________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________ 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. American LegalNet, Inc. www.FormsWorkflow.com