DCPLC-IndAuth Rev 3/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION L I Q U O R CONTROL D I V I S I O N Telephone: (860) 713-6210 Email: liquor.control@ct.gov Website: www.ct.gov/dcp STATEMENT OF PERSONAL HISTORY INSTRUCTIONS: All spaces must be completed – please print or type. This statement must be completed by the permittee and each person who is a backer for this liquor permit. If you need additional space, please attach a separate sheet. PERSONAL INFORMATION: Last Name Business Title First Name Shares Relationship to liquor permit Permittee Middle Name Aliases, other names known by, maiden name Backer Residence Street Address: State: Zip Code: City or Town: Home Telephone Number: ( ) Social Security Number Business Telephone Number: ( ) Motor Vehicle Driver’s License Number E-mail Address: State of Issue Sex Male Date of Birth / Place of Birth / Are you a US Citizen? Yes If no, Alien Reg Number Female Date & Place of Naturalization No II. EMPLOYMENT / PUBLIC OFFICES: Indicate any public offices now held by the applicant, individual backers, shareholders, corporate officers, llc members, etc. Give name of office holder(s) and identify by title, place and name of town, city, state or federal agency. Name Title Place Town, City, State or Federal Agency III. CRIMINAL HISTORY: List below all criminal convictions and alcohol-related motor vehicle convictions: If you have no such record, indicate by using the word “NONE”. Attach a separate sheet if needed. Conviction (List specific crime) Disposition (Sentence Imposed) Date State of Convicted Conviction I certify, under penalty of law that the information provided in this statement is the truth to the best of my knowledge. _____________________________________________________________________ Signature of permittee/backer completing this statement _________________________ Date American LegalNet, Inc. www.FormsWorkflow.com