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2. Full Name*
4. Other Names Used
6. Date of Birth*
   Date of Birth
7. Age*
8. Height
10. Weight
11. SSN #*
13. Local Address*
15. If less than 30 days at above address, how long do you expect to live there?
16. Local Phone*
18. Permanent Address*
22. Make of Vehicle you will use: *
23. Model?*
24. Year?*
26. License Plate # (Include State)*
27. Expiration Year:*
28. Driver's License # (include State)*
32. Company/Firm you are representing:*
34. Company Address:*
36. Name of Supervisor*
37. Supervisor's Phone #*
41. Have you ever been arrested?*

    1. Yes
    2. No
42. If yes, where?
44. Were you convicted?

    1. Yes
    2. No
46. If yes, list years, crimes and punishments imposed:
48. List the nature and type of goods, wares, services, or merchandise to be offered for sale:*
52. This permit will be issued conditional with the following restrictions:

    1. I certify that the statements made below are true and correct to the best of my knowledge.

    
    - Solicitation may ONLY be conducted between 9 AM and 8 PM. 

    - Solicitation permit will not be transferable to another person.

    - Permit will be carried at all times while engaging in soliciting.

54. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
56. Electronic Signature
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field