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Age Statement Form - Connecticut

Age Statement Form Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide .
 Fillable pdf Last Modified 9/17/2009
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AGE STATEMENT FORM Permittee / Agent: Date: I (Please Print Name) 20 hereby represent to ,a (Permittee / Agent Name) Permittee of the Connecticut Department of Consumer Protection that I am over the age of 21 years, having been born on 19 at (Month / Day) (Town / State) This statement is made to induce said permittee to sell or otherwise furnish alcoholic beverages to the undersigned. I understand that Title 30 of the Connecticut General Statutes prohibits the sale of alcoholic liquor to any person who is not twenty-one years of age. I understand that I am subject to a fine of one hundred dollars for the first offense and not more than two hundred fifty dollars for each subsequent offense for willfully misrepresenting my age for the purposes set forth in this statement. C.G.S. 30-89 (Signature) TO BE COMPLETED BY PERMITEE OR AGENT: NAME: ADDRESS: ID TYPE: ID NUMBER: Photo ID YES NO 2ND Form of ID ID TYPE: ID NUMBER: Photo ID YES NO Optional DCP 8/04 American LegalNet, Inc.
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