Substitute Permittee Application

For Official Use Only DCPLC ­ Sub Permittee App Rev 10/12 1 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp/liquorcontrol SUBSTITUTE PERMITTEE APPLICATION (FOR ON-PREMISES AND OFF-PREMISES LIQUOR PERMITS) Please print clearly or type the information entered on this application. An application and permit fee is required. Please submit the required fee of $30.00. Checks and/or money orders should be made to "Treasurer, State of Connecticut" and must accompany this application. The application fee is non-refundable. Return your completed application, documentation and appropriate fee to: Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 Section A: NEW PERMITTEE INFORMATION 1. New Permittee Name (First, Middle, Last) 2. Permittee Residence Street Address City State Zip Code 3a. Phone Number: 3b. Fax Number: 3c. E-mail Address 4. Is this a Permanent Substitution? YES NO 5. Beginning Date of Substitution 6. Are you able to read and understand English? YES NO Section B: CURRENT BUSINESS LOCATION/PERMITTED PREMISES 7. Permit Number 8. Trade Name 9. Business Street Address City State Zip Code 10a. Phone Number: 10b. Fax Number: 10c. E-mail Address Section C: BACKER-OWNER INFORMATION 11. Backer Name (Corporation, LLC, Partnership, Sole Proprietorship, etc.) 12. Name of Authorized Representative of the Backer (Person's Name) American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ Sub Permittee App Rev 10/12 2 Section D: CURRENT OR PREVIOUS LIQUOR PERMITS HELD BY PERMITTEE This section applies to the NEW permittee applicant who is currently listed or was previously listed as a permittee, is or was a sole proprietor, partner or a member of a partnership organization, corporation, and or members of a limited liability organization or unincorporated associations. Attach a separate sheet if needed. 13a. Does the new permittee currently hold a liquor permit? YES 13b. Has the new permittee or Backer held a liquor permit in the past? NO YES NO If yes, please complete the permit information for each past or present permit below 14a. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 15b. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 17. Have any of the permits listed above been revoked, suspended or denied in CT or any other state? YES NO If yes, attach a statement detailing the enforcement action(s) taken including violation(s), date(s), and the circumstance(s) involved. Section E: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 18. New Permittee Certification (To be signed by new permittee applicant, Signed by New Permittee Applicant identified in "Section A" of this application) I certify that the information provided in this application is true to the best of my X__________________________________________________ knowledge. 19. Backer Certification (To be signed Date by backer or the authorized representative Signed by Backer or Authorized Representative of Backer of the backer) Date I certify that the information provided in X__________________________________________________ this application is true to the best of my knowledge and that the permittee Print name of Backer or Representative Title of Backer or applicant identified in "Section C" of this Representative application is designated as my principal representative on the premises for which this application is being submitted. American LegalNet, Inc. www.FormsWorkFlow.com