Form Center

2. Time Limit
   9 a.m. to Dusk Only
4. Date
   Date
5. Non-Refundable Application Fee
   $25
7. Background Check Consent

   1. Yes

   I hereby give consent to have my background searched. A background search may include, but not be limited to a criminal history inquiry, employment records, credit records and other pertinent information. I understand that I must provide my full name, date of birth, driver’s license number and a copy of the license, and any alias or other name(s) I have been known by. I understand that this search will be conducted prior to the issuance of a solicitors permit.
11. Applicant Information
13. Name
14. Home Address
16. State
17. Zip Code
19. Cell Phone
20. Date of Birth
    Date of Birth
22. Felony Convictions

    1. Yes

    Have you ever been convicted, even if expunged, of a felony or of any offense involving violence or threats of violence, possession or use of weapons, theft, fraud or sexual misconduct? If you answered yes, give details below. Include charges, dates and places of convictions and whether you are currently on probation, parole or any other form of supervision.
24. Conviction Details
28. Vehicle Information
30. Year
31. Make
32. Color
34. Plate Number
35. State
37. Owner's Name
38. Owner's Address
42. Business Information
44. Nature of Business &/or Goods to be Sold
46. Company Name
47. Address
49. City
50. State
51. Zip Code
53. Phone
54. Length of Time You've Been Employed or Engaged in the Business
56. Owner/Manager Authorization
    I, owner/manager of the business do hereby authorize the applicant to represent the company in conducting business.
58. Business Owner/Manager Name
59. Date
    Date
Leave This Blank:


60. Print Only

* indicates a required field