CONSUMER COMPLAINT STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION 165 Capitol Avenue � Hartford, CT 06106 E-Mail: dcp.liquorcontrol@ct.gov Fax Number: (860) 713-7235 Agent Number: (860) 713-6210 WHAT IS YOUR NAME? WHAT IS YOUR DAYTIME TELEPHONE NUMBER (INCLUDING AREA CODE)? WHAT IS YOUR EVENING TELEPHONE NUMBER (INCLUDING AREA CODE)? E-MAIL ADDRESS: STATE ZIP CODE WHAT IS YOUR HOME ADDRESS? STREET ADDRESS CITY MY COMPLAINT INVOLVES THE FOLLOWING LICENSED LIQUOR ESTABLISHMENT: NAME OF BUSINESS STREET ADDRESS CITY PERMIT NUMBER, IF KNOWN NATURE OF COMPLAINT: � SALE TO MINOR(S) � SALE TO INTOXICATED PATRONS � REFILLING � AFTER HOURS � PURCHASE FOR RESALE � UNLAWFUL GAMBLING � PERFORMER CONDUCT � OTHER ACTIVITY (EXPLAIN) 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