Reg. Number: __________________
Date Received: _________________
Date Approved: ________________
Date Expired: __________________
To: City of Mount Carroll
Subject: Application for a License For City Roadblock
Name of organization _______________________________________________________________
Address of organization _____________________________________________________________
Telephone number of organization ____________________________________________________
Name of local representative of organization ____________________________________________
Address of local representative of organization __________________________________________
Phone number of local representative of local organization _________________________________
1. Is your soliciting agency registered with the Attorney General as a charitable organization as provided by “An Act to Regulate Solicitation and Collection of Funds for Charitable Purposes, Providing for Violations Thereof, and Making an Appropriation Therefor”, approved July 26, 1963, as amended. Yes_______________ No ___________________
2. Is your organization engaged in a statewide fundraising activity?
Yes_______________ No ___________________
3. Proof of insurance for at least $1,000,000 with policy showing that the city is additionally insured. Yes_______________ No ___________________
4. The location for which permit to solicit is being sought.
RT 64/RT 78 intersection _________________ Market/Main St. intersection _______________
5. Date and time of day for solicitation. ________________________________________________
6. Number of persons to solicit at each location.
RT 64/RT 78 intersection _________________ Market/Main St. intersection _______________
(Ord. 2012-03-13, passed 3-13-2012)