CPLBD Amend Rev 8/18 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LICENSE SERVICES DIVISION 450 Columbus Blvd, Ste.801 Hartford, CT 06103 Email: dcp.brands@ct.gov Website: www.ct.gov/dcp Liquor Brand Label Registration Amendment Form Name of Company Street Address City State Zip Code CT Liquor Permit Number Email Address (for all correspondence, approval of label, application deficiencies, etc.) Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Individual Product Brand Name (as it appears on the label) CT LBD Number Check the type of change(s) requested for this brand label: Change of design and/or verbiage Change of proof Types of Label Changes Fee Schedule (fee applies for a 3-year period) Fees are non-refundable and non-transferable Change of design and verbiage-change in the descriptive phraseology on the label as originally approved $100.00 per label change fee Change of proof-change in the contents of the container as originally approved $200.00 per label change fee -includes design and verbiage, if applicable Change for a brand manufactured in Connecticut-a brand manufactured in Connecticut by a Connecticut Manufacturer $ 15.00 per label change fee -includes design, verbiage and/or proof For Official Use Only 1.The company name, address, Connecticut liquor permit number and email address must be indicated on this application. 2.The brand label registration amendment form must be completed with the brand name(s) and the CT liquor brand label registration number and type of change(s) . An amendment form is not required for color, shading, or label format or for a change in vintage. 3.Attach Federal Label Approval for brand(s) requesting revision(s). 4.Attach one set of old label(s) and one set of new label(s) requesting revision(s). Please circle all revisions on the new label. 5.A check/money order for the applicable fee(s) payable to 223Treasurer, State of Connecticut224 must accompany this form. American LegalNet, Inc. www.FormsWorkFlow.com