Crime Arresting Agency Date of Conviction Court Where Convicted
Check if you have never been convicted of a crime
Check here if an additional sheet is attached for criminal history
Name of Applicant: Date of Application:
Individual's Relationship to Business
Name Address Phone Number
Check here if an additional sheet is attached for EMPLOYEES, PRINCIPALS IN BUSINESS, OFFICERS, SHAREHOLDERS, FINANCIAL BACKER or CREDITORS
I hereby certify that the information provided is true and accurate. I understand that if I have falsified any information in this application
or on the attached _____ pages, I will not be entitled to the license sought or this license may be revoked or suspended, after notice
and hearing, if information is found to be false after the license has been issued. I fully understand that if I intentionally make a
statement that is untrue and which is intended to mislead a public servant in the performance of his or her official function, I will be in
violation of Section 53a-157b of the Connecticut General Statutes for False Statement and may be subject to arrest.
Date: ______________________________ Signature of Applicant: ________________________________________________________
(Must be signed in the presence of a Notary Public)
Subscribed and sworn to before me this ____________ day of _______________, 20_______, in accordance with the Connecticut
Signature of Notary Public Print Name of Notary Public
My Commission expires: ________________________
Check here if an additional sheet is attached for Internet Web Sites and Accounts
CRIMINAL HISTORY - List all crimes for which you have been convicted.
EMPLOYEES, PRINCIPALS IN BUSINESS, OFFICERS, SHAREHOLDERS, FINANCIAL BACKER or CREDITORS
List all persons required to be reported under Chapter 409 of the C.G.S.
INTERNET WEB SITES, ACCOUNTS OR EMAIL ADDRESSES List all sites, accounts and addresses required under C.G.S. Chapter 409.