STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION L I Q U O R C O N T RO L D I V I S I O N INFORMATION RELEASE AUTHORIZATION I authorize any agent from the State of Connecticut, Department of Consumer Protection, to information relating to my activities, from employers, criminal justice agencies, financial institutions, credit bureaus, consumer reporting agencies and retail business establishments, or This information may include, but is not limited to, my residential, personal, or criminal history financial and credit information. obtain any or lending individuals. record, and I further authorize release of my criminal history from criminal justice agencies for the purpose of determining my eligibility for a liquor permit as either permittee and/or backer. I understand that the information releases is for official use by the State of Connecticut, Department of Consumer Protection, and that these users may redisclose this information authorized by law. I release any individual, including records custodians, from all liability for damages that may result to me because of compliance, or any attempts to comply, with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me. Failure to complete this form may result in delays of obtaining your permit and may result in the permit being denies if this information can not otherwise be obtained. Name of Applicant (First Name, Middle Initial, Last Name) Residence Street Address City PO Box State Home Telephone Number (area code) Social Security # Driver’s License # Zip Code Date of Birth State I CERTIFY, UNDER PENALTY OF LAW (SEC. 53a-157, CLASS A MISDEMEANOR), THAT THE ABOVE PROVIDED INFORMATION IN THIS APPLICATION IS THE TRUTH TO THE BEST OF MY KNOWLEDGE. Signature of Applicant__________________________________________________ Date__________________ Subscribed and sworn before me this day of ______________________________________________________________ Signed (Commissioner of Superior Court/Notary Public/Justice of the Peace) 20__________ _____________________ My Commission Expires American LegalNet, Inc. www.FormsWorkflow.com