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CITY OF DOUGLAS Door-to-Door Commercial Solicitation Application Information Regarding Applicant/Entity: Company Name: Company Tax ID#: Company Address: City: State/ZIP: Company Phone Alt. Phone: Wyoming Sales Tax Nature of Goods/Services to be Solicited: Responsible Person or Entity (if different from above): Name/Address/Phone of Immediate Supervisor (if applicable): Comprehensive Liability Insurance Carrier: (Note: City must be named an additional insured; amount of coverage shall be not less than $500,000 to $1,000,000 in coverage; proof of insurance is required.) Surety Performance Bond Company (A performance bond in the amount of ten thousand ($10,000) dollars signed by a surety company authorized to do business in the state of Wyoming is required if deposits are required by applicant from customers; copy of bond must be provided to the City of Douglas): Provide the following information for each individual to be authorized under this permit. Please attach a separate sheet of paper if more space is needed. 1. Name, address, phone number and date of birth; 2. A current copy of the person’s criminal background check as maintained by the Wyoming Bureau of Investigation; 3. A five year driver’s history from the Wyoming Department of Transportation dated no more than sixty (60) days prior to the date of the application; 4. A description of the individual, including height, weight, color of eyes and color of hair; 5. Proof of identification by submittal of any of the following that bear a photograph of said person: i. A valid U.S. driver’s license or identification card issued by any state; ii. A valid United States uniformed service identification card; iii. A valid U.S. passport and work Visa; or iv. U.S. Citizenship & Immigration Services Green Card. 6. A description of all vehicles that the applicant will use and license plate number; 7. License plate for every vehicle to be used by individual’s covered under this permit; and 8. Any other information determined to be relevant by the administrative official. ---PAGE BREAK--- Transient Merchant Application Page 2 of 2 Updated form - 2013 Full Name: Birth Date: Social Security Number: Weight: Hair Eye Color: All Former Names and/or Aliases: Driver’s License State: Expires: Vehicle Model: Make: Year: Vehicle License #/State: Address: City: State/ZIP: Since: Home Phone: Cell Phone: Full Name: Birth Date: Social Security Number: Weight: Hair Eye Color: All Former Names and/or Aliases: Driver’s License State: Expires: Vehicle Model: Make: Year: Vehicle License #/State: Address: City: State/ZIP: Since: Home Phone: Cell Phone: Full Name: Birth Date: Social Security Number: Weight: Hair Eye Color: All Former Names and/or Aliases: Driver’s License State: Expires: Vehicle Model: Make: Year: Vehicle License #/State: Address: City: State/ZIP: Since: Home Phone: Cell Phone: Full Name: Birth Date: Social Security Number: Weight: Hair Eye Color: All Former Names and/or Aliases: Driver’s License State: Expires: Vehicle Model: Make: Year: Vehicle License #/State: Address: City: State/ZIP: Since: Home Phone: Cell Phone: TO BE COMPLETED BY CITY CLERK Filing Fee Receipt # Date of Approval License # issued Date Received Expiration Date