On-Premises Liquor Permit Application - CT.gov

DCPLC – On-Premises App Rev 1/11214. Permittee Name (First, Middle, Last)Section C: PERMITTEE APPLICANT INFORMATION15. Permittee Residence Street Address City State Zip Code16. Permittee Telephone Number 17. Permittee Fax Number 18. Permittee Email Address19. NameSection D: PREFERRED MAILING ADDRESSCheck () one box below and enter address if different than Business or Permittee AddressBUSINESS ADDRESS PERMITTEE ADDRESS ADDRESS BELOW20. Address City State Zip CodeSection E: BACKER INFORMATION* Each backer must also complete the “Authorization for Release of Financial Information & Statement ofPersonal History” form that accompanies this application21. Backer: Please select the type of Backer (individual or legal entity that owns the business) belowPlease check () only oneSoleProprietorship/OwnerCorporationLimitedLiabilityCompanyPartnershipLimitedLiabilityPartnershipUnincorporatedAssociation22. Name of Corporation, LLC, Partnership, Sole Proprietorship, etc.23. Street Address City State Zip Code24. Backer Telephone Number 25. Backer Fax Number 26. Backer Email Address27. Backers: List individuals below (for example; sole owner, corporate officers, members, etc.) Attach additional sheet if needed.a. Name (First, Middle, Last) Title % of ownership or # of sharesb. Name (First, Middle, Last) Title % of ownership or # of sharesc. Name (First, Middle, Last) Title % of ownership or # of sharesd. Name (First, Middle, Last) Title % of ownership or # of shares