Reg. Number: __________________
Date Received: _________________
Date Approved: ________________
Date Expired: __________________
To: City of Mount Carroll
Office of the Chief of Police
302 N. Main St.
Mount Carroll, IL 61053
Subject: Application for a License For City Solicitors
I hereby make application for a license certificate for solicitors in the City of Mount Carroll, IL as set forth under Mount Carroll Ordinance 2012-03-13 passed on 3-13-2012. I am submitting the following information in response to questions asked for the purpose of inducing a favorable act on this application. I further understand that any false statement herein contained in this application constitutes grounds revocation of such license in addition to possible prosecution for perjury or false swearing. This application is good for only the person applying. If any other subjects wish to solicit, they must fill out an application themselves.
1. Applicant’s Full Name: ____________________________________________
Applicant/s Address: ______________________________________________
Permanent Residence ______________________________________________
Length of Residency _________________ Phone Number _______________
Secondary Residence ______________________________________________
Length of Residency _________________ Phone Number _______________
2. Applicant’s Physical Description
Race __________________ Sex _____________ Date of Birth _____________
Height ___________ Weight ___________ Eyes ___________ Hair ________
3. Marital Status _______________ If married, spouse’s name _________________
4. Drivers License Number or State ID Card State of Issuance _______________
5. Name of Firm Representing: _________________________________________
Type of Business: __________________________________________________
Address of Firm Representing ________________________________________
Phone Number _________________ Years Representing ________________
6. Have you ever been convicted of a felony under the laws of the State of Illinois or any other state?
YES ______________ NO __________________
If yes, please explain. ___________________________________________________
_____________________________________________________________________
7. Have you ever been arrested for any crime? YES ____________ NO _____________
If yes, please explain. ___________________________________________________
_____________________________________________________________________
Have you ever been convicted of any crime? YES ____________ NO ____________
If yes, please explain. ___________________________________________________
_____________________________________________________________________
8. List all vehicles to be used in conducting said requested solicitation:
Make _________________ Model ____________ Year __________________
License Number ____________________ State of Issuance ___________________
List all vehicles to be used in conducting said requested solicitation:
Make _________________ Model ____________ Year __________________
License Number ____________________ State of Issuance ___________________
List all vehicles to be used in conducting said requested solicitation:
Make _________________ Model ____________ Year __________________
License Number ____________________ State of Issuance ___________________
9. Date of latest previous application for a certificate with this department? __________
10. Briefly state the purpose for applying for this application and the type or scope of activities to be conducted. _____________________________________________________________
______________________________________________________________________
Will product be delivered at the time of sale? YES ____________ NO ____________
11. For what period of time are you applying for this certificate? Maximum number of days allowed is six. From _____________ To ___________________
12. Accompanying this application shall be:
a. Government issued ID-Driver License, Social Security or State Identification Card
b. At least three (3) letters of recommendation from reliable citizens
c. Fingerprints and photographs that will be taken by the Mount Carroll Police Department
13. I am not now violating any ordinance of the City of Mount Carroll or law of the State of Illinois in the conduct of my business, and do not intend to violate any such laws or ordinances, and I consent and agree, in making this application, that any such violation by me or my employees shall constitute cause for revocation of the License applied for.
Signature ___________________________
14. I understand that the certificate of registration issued pursuant to this application is not transferable and is void after the date of expiration affixed to the license.
Signature ___________________________
STATE OF ILLINOIS
COUNTY OF CARROLL
_______________ Being by me duly sworn on oath deposes and says that he has read the foregoing application by him subscribed, and that the matters and things set forth therein are true.
Signature ___________________________
Subscribed and sworn to me before this _____________ day of ___________ 20_____
Sales are prohibited until license is approved. Applications may take one to two business weeks to be processed.
(Ord. 2012-03-13, passed 3-13-2012)