AGE STATEMENT FORM
Permittee / Agent:
Date:
I (Please Print Name) hereby represent to (Permittee / Agent Name), a Permittee of the Connecticut Department of Consumer Protection that I am over the age of 21 years, having been born on (Month / Day / Year) at (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
TO BE COMPLETED BY PERMITTEE OR AGENT:
NAME:
ADDRESS:
ID TYPE:
ID NUMBER:
Photo IDYESNO
2ND Form of ID Optional
ID TYPE:
ID NUMBER:
Photo IDYESNO
DCP 8/04 · electronic form