DCPLC-stip-remov Rev 9/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp STIPULATED AGREEMENT FOR REMOVAL Date: _____________________ Trade Name: ____________________________________________________ Town: __________________________________________________ I, THE UNDERSIGNED, ______________________________________________________________, in recognition of the fact the Department of Consumer Protection has granted permission for the removal of my permit from: _______________________________________________________ to _______________________________________________________ hereby agree and stipulate as follows: 1) Complete proper publication notice, and 2) Meet the satisfactory inspection and investigation by the investigating agent. IN THE EVENT I fail to comply with above stipulated, and it becomes necessary for the Department of Consumer Protection to revoke my permit, then I hereby willingly and knowingly surrender my statutory right to appeal from the decision of the Liquor Control Commission revoking my permit, and I further agree that any such appeal shall under no circumstances act as a stay of execution of the order of revocation. I do hereby affirm that the information contained in this affidavit is true to the best of my knowledge. Signature of permittee, backer or authorized representative of the backer: X _____________________________________________________ Date: ______________________ Subscribed and affirmed before me: Signed X _________Date (Commissioner of Superior Court, Notary Public, Justice of Peace) _______ American LegalNet, Inc. www.FormsWorkFlow.com