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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 .
 Fillable pdf Last Modified 1/22/2014
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LIS Appl Rev 1/13 For Official Use Only STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION License Services Division 165 Capitol Avenue Hartford, CT 06106 Email: dcp.licenseservices@ct.gov Web site: www.ct.gov/dcp Application for Liquor Wholesaler Salesman Certificate You must file an application for certificate not later than ten (10) days after the date of initial employment. This completed application must be accompanied by a non-refundable fee in the amount of $50.00 made payable to "Treasurer, State of Connecticut" and returned to the above address. All certificates expire biennially on January 31st. Applicant Information Name of Individual Street Address City State Zip Code Telephone Number Email Address Social Security Number Date of Birth Are you a minor or a person who holds a position that would prohibit you from obtaining a liquor permit? (See CT General Statutes Yes No Section 30-45 for a list of such individuals) Have you been convicted of a felony crime or an alcohol related motor vehicle violation? Yes No If yes, attach a statement including the date(s) and nature of conviction(s), the court(s) where the cases were disposed of and a description of the circumstances. Certification I certify, under penalty of law (Section 53a-157b, a Class A Misdemeanor) that the information provided in this application is the truth to the best of my knowledge. _______________________________________________________________________ ______________________ Signature of Applicant Date Subscribed and sworn to before me, this __________ day of ___________________________ 20 _______ ________________________________________________________________________ ______________________ Signature of Notary Public, Justice of the Peace, Commissioner of Superior Court My Commission Expires Employer (Liquor Wholesaler) Information Name of Wholesaler Street Address Wholesaler CT Permit Number City Date Individual was Hired State Zip Code Certification I certify that the above named salesperson is authorized to sell or offer for sale alcoholic liquor to any retailer of alcoholic liquor on behalf of the liquor wholesaler. _______________________________________________________________________ ______________________ Signature of Employer (Officer or Authorized Agent) Date Subscribed and sworn to before me, this __________ day of ___________________________ 20 _______ ________________________________________________________________________ ______________________ Signature of Notary Public, Justice of the Peace, Commissioner of Superior Court My Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com
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