Form DPS-403-C "Application for Licensing Under C.g.s. Chapters 409/414" - Connecticut

What Is Form DPS-403-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2011;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DPS-403-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DPS-403-C "Application for Licensing Under C.g.s. Chapters 409/414" - Connecticut

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Application for Licensing under C.G.S. Chapters 409/414
Date of Application:
Date of Fingerprint:
Type of Application:
Renewal fee waived with
Pawnbroker
Renewal $25
Initial License fee $50
Secondhand License
STATE OF CONNECTICUT
Secondhand Dealer
Initial License fee $250
Renewal $100
Department of Emergency Services and
Precious Metal or Stones Dealer
Initial License fee $10
Renewal $10
Public Protection
Division of State Police -Special Licensing
Name of Business:
1111 Country Club Road
Middletown, CT 06457-2389
Phone: 860-685-8046
Type of Business:
Fax: 860-685-8496
www.ct.gov/dps
Last Name of Applicant:
First Name of Applicant:
Sex:
Place of Birth
Middle Name of Applicant:
Age:
Race:
Applicant's Date of Birth:
BUSINESS ADDRESS
APPLICANT'S RESIDENTIAL ADDRESS
Street Address:
Street Address:
Town or City/State:
Town or City/State:
Zip/Postal Code:
Zip/Postal Code:
Business Phone:
Home Phone:
Applicant's Current Occupation:
Cell Phone:
List all locations used or intended to be used for the purchase, receipt, storage or sale of property :
Physical address of property (include unit #)
City/Town & State, Zip Code
Use/intended use:
List all of the residential addresses used by the applicant over the past five years:
Street Address
City/Town & State, Zip Code
Dates resided from/to :
Check here if an additional sheet is attached for locations
Check here if an additional sheet is attached for
used by business for purchase, receipt, storage or sale of property
applicant's residential addresses
Page 1
DPS-403-C New 10/1/2011
Application for Licensing under C.G.S. Chapters 409/414
Date of Application:
Date of Fingerprint:
Type of Application:
Renewal fee waived with
Pawnbroker
Renewal $25
Initial License fee $50
Secondhand License
STATE OF CONNECTICUT
Secondhand Dealer
Initial License fee $250
Renewal $100
Department of Emergency Services and
Precious Metal or Stones Dealer
Initial License fee $10
Renewal $10
Public Protection
Division of State Police -Special Licensing
Name of Business:
1111 Country Club Road
Middletown, CT 06457-2389
Phone: 860-685-8046
Type of Business:
Fax: 860-685-8496
www.ct.gov/dps
Last Name of Applicant:
First Name of Applicant:
Sex:
Place of Birth
Middle Name of Applicant:
Age:
Race:
Applicant's Date of Birth:
BUSINESS ADDRESS
APPLICANT'S RESIDENTIAL ADDRESS
Street Address:
Street Address:
Town or City/State:
Town or City/State:
Zip/Postal Code:
Zip/Postal Code:
Business Phone:
Home Phone:
Applicant's Current Occupation:
Cell Phone:
List all locations used or intended to be used for the purchase, receipt, storage or sale of property :
Physical address of property (include unit #)
City/Town & State, Zip Code
Use/intended use:
List all of the residential addresses used by the applicant over the past five years:
Street Address
City/Town & State, Zip Code
Dates resided from/to :
Check here if an additional sheet is attached for locations
Check here if an additional sheet is attached for
used by business for purchase, receipt, storage or sale of property
applicant's residential addresses
Page 1
DPS-403-C New 10/1/2011
Name of Applicant:
Date of Application:
EMPLOYMENT HISTORY
(past five years)
1.
Current or most recent
Name of Employer:
Name of last supervisor:
From:
To:
Dates of employment:
Complete Address:
Phone #:
Last job title:
2.
Name of Employer:
Name of last supervisor:
From:
To:
Dates of employment:
Complete Address:
Phone #:
Last job title:
3.
Name of Employer:
Name of last supervisor:
From:
To:
Dates of employment:
Complete Address:
Phone #:
Last job title:
Check here if an additional sheet is attached for applicant's employment history
PREVIOUS EXPERIENCE
Has applicant had previous experience in the type of business for which a license is being sought under this application:
Name of Business:
Name of last supervisor:
From:
To:
Dates of employment:
Complete Address:
Phone #:
Last job title:
Check here if an additional sheet is attached for applicant's previous experience
Page 2
DPS-403-C New 10/1/2011
Name of Applicant:
Date of Application:
CRIMINAL HISTORY
Check if you have never been convicted of a crime
- List all crimes for which you have been convicted.
Crime
Date of Conviction
Court Where Convicted
Arresting Agency
Check here if an additional sheet is attached for criminal history
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.
Individual's Relationship to Business
Name
Address
Phone Number
Select One
Select One
Select One
Select One
Check here if an additional sheet is attached for
EMPLOYEES, PRINCIPALS IN BUSINESS, OFFICERS, SHAREHOLDERS, FINANCIAL BACKER or CREDITORS
INTERNET WEB SITES, ACCOUNTS OR EMAIL ADDRESSES
List all sites, accounts and addresses
required under C.G.S. Chapter 409.
#1
#2
#3
#4
Check here if an additional sheet is attached for
Internet Web Sites and Accounts
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, if the information is found to be false after the license is
issued, the license may be revoked or suspended after notice and hearing. 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
General Statutes.
_____________________________________________
__________________________________________
Signature of Notary Public
Print Name of Notary Public
My Commission expires: ________________________
Page 3
DPS-403-C New 10/1/2011
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