CITY OF GLEN DALE APPLICATION FOR CITY LICENSE, SOLICITORS AND CANVASSERS

LIST FULL NAME ________________________________________________________

PERMANENT HOME ADDRESS ____________________________________________

DATE OF BIRTH _____________________ SOCIAL SECURITY ____________________

FULL LOCAL ADDRESS ____________________________________________________

Attach copy of operators license or description and photograph of

APPLICANT ______________________________________________________________

NAME OF EMPLOYER ________________________________________________

ADDRESS OF EMPLOYER _________________________________________________

TELEPHONE NUMBER ____________________________________________________

DATES OF SOLICITATION __________________________________________________

Do you have a West Virginia Business license?   Circle   Yes / No

LIST WEST VIRGINIA TAX IDENTIFICATION NUMBER _____________________________________

TYPE OF VEHICLE TO BE USED IN SOLICITATION: LICENSE __________________ STATE _____

YEAR _______ COLOR __________ MAKE ___________ MODEL ____________

Are you taking orders for goods?  Circle   Yes / No

EXPECTED DELIVERY DATE ____________ OR DELIVERY AT TIME OF ORDER _____________

LIST TWO CREDIT REFERENCES   __________________________________________________

                                                     ___________________________________________________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? Circle  Yes / No

IF YES. EXPLAIN _______________________________________________________

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.

DATE _________________ SIGNATURE ____________________________________

PERMIT TO BE USED DURING THE DAYLIGHT HOURS ONLY

DATE ___________ SIGNATURE _______________________ PERMIT # ________________

EXPIRATION DATE _____________ FEE _____________

SECURITY AMOUNT $_______________

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