APPENDIX A: PRIVILEGE LICENSES FOR SOLICITORS AND CANVASSING
1. NAME: ___________________________________________________
2. SOCIAL SECURITY NO. __________________ DATE OF BIRTH: ____________
3. HEIGHT: ________ WEIGHT: _______   HAIR COLOR: ________ EYES: ____________
4. PERMANENT HOME ADDRESS:   TELEPHONE:  ________________________
______________________________________________________________________________
Street                  City         State      Zip
5. LOCAL ADDRESS:            TELEPHONE: ________________________
______________________________________________________________________________
Street                  City         State      Zip
6. BRIEF DESCRIPTION OF THE NATURE OF BUSINESS AND GOODS TO BE SOLD:
__________________________________________________________________________________________
7. NAME OF EMPLOYEE: __________________________________
ADDRESS:                     TELEPHONE: ________________________
______________________________________________________________________________
Street                  City         State      Zip
8. PROVIDE A STATEMENT SHOWING CREDENTIALS ESTABLISHING THE EXACT RELATIONSHIP WITH APPLICANT AND EMPLOYER. (ATTACH STATEMENT)
9. The length of time for which the right to do business is desired:
   From: ____________________  To: ____________________
10. Place where goods will be manufactured or produced: _______________________________
_______________________________________________________________________________
_______________________________________________________________________________
Place where goods are located at time the application is filed: ____________________________
______________________________________________________________________________
Proposed method of delivery:
_________________________________________________________________________________
11. The name of at least two reliable property owners of Gaston County, North Carolina, who will certify as to the applicant’s good character and business responsibility or, in lieu of the name of references such other available evidence as to the good character and business responsibility of the applicant.
NAME: __________________________________
ADDRESS:                     TELEPHONE: __________________
_________________________________________________________________________________
12. Have you been convicted of any crime, misdemeanor or violation of my municipal ordinance?
   YES ____   NO ____
IF YES, ATTACH LIST SHOWING THE DATE OF THE OFFENSE, THE NATURE OF THE OFFENSE AND THE PUNISHMENT OR PENALTY ASSESSED.
13. A SURETY BOND UNDER THE LAWS OF NORTH CAROLINA IN THE AMOUNT OF $1,000 SHALL BE SUBMITTED WITH APPLICATION.
14. Attach a photograph, taken within sixty (60) days prior to application 2” x 2”, showing the head and shoulders in a clear and distinguishing manner.
15. Badge issued by the Town of Dallas shall be worn at all times:
16. List description of vehicle to be used while soliciting
Make: ________________   Model: ______________   Year: ________
Color: ________________   License No.: __________   State: ________
17. Application will be submitted to the Town Clerk who will forward it to the Chief of Police for investigation. Approximately 30 days for processing.
18. If application is approved, license will be revoked if my provisions of the Town Ordinance are violated.
I, _______________________________________________ the applicants state that the above information is true and accurate and contains no misstatements. I further understand that if my of the above information is incorrect that this application is automatically voided.
                     ____________________________________
                     Signature
Date: ____________
________________________________________________________________________________
TOWN USE:
Date Received: ___________________   Date submitted to Chief: _________________
Date Received from Chief: _______________
Date Approved:___________________   Date Disapproved: ___________________   
(Prior Code, § J-V-Form-1)