Connecticut > Statewide > Department Of Consumer Protection > Liquor Control Division
Application For Liquor Wholesaler Salesman Certificate CPLIS-01 - Connecticut
| Application For Liquor Wholesaler Salesman Certificate Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide . |
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For Official Use Only CPLIS-01, REV 3/06 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6200 Email: liquor.control@ct.gov Website: www.ct.gov/dcp APPLICATION FOR LIQUOR WHOLESALER SALESMAN CERTIFICATE INSTRUCTIONS: You must file an application for certificate not later than ten (10) days after the date of initial employment. If you change employers, you must refile with the Department of Consumer Protection within ten (10) days. The individual applying for the certificate must complete this form. All spaces must be completed please print or type. à This application must be accompanied by a non-refundable fee in the amount of $25.00, made payable to State of Connecticut" and returned to: "Treasurer, Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 Applicant's Name (First Name, Middle Initial, Last Name) Applicant's Street Address City or Town State Zip Code Social Security Number Date of Birth Telephone Number (with area code) Are you a minor or a person who holds a position that would prohibit you from obtaining a liquor permit? (See CT General Statutes Section 30-45 for a list of such individuals) Yes No Yes No Have you been convicted of a felony crime or an alcohol related motor vehicle violation? If yes, attach a statement including the date(s) and nature of conviction(s), the court(s) where the case(s) were disposed of and a description of the circumstances. Wholesaler Employer Name Date Hired Street Address City or Town State Zip Code I CERTIFY UNDER PENALTY OF LAW THAT THE ABOVE PROVIDED INFORMATION IN THIS APPLICATION IS THE TRUTH TO THE BEST OF MY KNOWLEDGE ______________________________________________________ Signature of Applicant (Employee) Subscribed and sworn to before me ____________________ Date Notary Seal ______________________________________________________ Signature of Notary Public ______________________________________________________ Signature of Employer (Officer or Authorized Agent) Subscribed and sworn to before me ___________________ Date ____________________ Date Notary Seal ______________________________________________________ Signature of Notary Public ___________________ Date American LegalNet, Inc. www.FormsWorkflow.com
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