Application No. ___________________ Annual license fee due May 1: $_________
(PLEASE TYPE OR PRINT)
1. Applicants Name: ____________________________________ PHONE ( )________________
2. Applicant's Address: ________________________________________________________________
City ___________________________________ State _______________ ZIP __________
3. Length of resident at above address _______ years ________ months
4. Applicant's Date of Birth ________ / ________ / Social Security No. ____________________
5. Marital Status ____________________ Name of Spouse ______________________________
6. Citizenship of Applicant ______________________________________________________________
7. Business Name _________________________ PHONE ( ) _________________
8. Business Address _________________________________________________________________
City ____________________________ State ______________ ZIP _____________
9. Length of Employment ________ years __________ months
10. All residences and addresses for the last three (3) years if different than above:
_____________________________________________________________________________________
_____________________________________________________________________________________ _____________________________________________________________________________________
11. Name and Address of employers during the last three (3) years if different than above:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. List the last three (3) municipalities where applicant has carried on business immediately preceding the date of application:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. A description of the subject matter that will be used in the applicant's business:
_____________________________________________________________________________________
14. Has the applicant ever had a license in this municipality? [ ] Yes [ ] No
If so, when ______________________________________
15. Has a license issued to this applicant ever been revoked? [ ] Yes [ ] No
If "yes", explain: _________________________________
16. Has the applicant ever been convicted of a violation of any of the provisions of this Code, etc.?
[ ] Yes [ ] No
If "yes", explain: _____________________________________________________________________
17. Has the applicant ever been convicted of the commission of a felony? [ ] Yes [ ] No
If "yes", explain: __________________________________
18. LICENSE DATA: Term of License ________________________________________________
Fee for License $______________.________
Sales Tax Number ______________________________________________
License Classification ___________________________________________
19. LIST ALL OWNERS IF LICENSE IS FOR LOCAL BUSINESS (PERMANENT):
_____________________________________ ______________________________________
_____________________________________ ______________________________________
_____________________________________ ______________________________________
_____________________________________ ______________________________________