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Page 1 of 3 CITY OF DOUGLAS PAWNBROKER'S LICENSE APPLICATION, TERM OF INFORMATION REGARDING APPLICANT: 1. Full Name: 2. Social Security 3. Home Phone 4. Address of Premise (City/State/ZIP): 5. Address of Residence (City/State/ZIP): 6. Driver’s License 7. State: 8. Expiration Date: INFORMATION REGARDING COMPANY: 9. Company Name: 10. Company Address (City/State/ZIP): 11. Company TIN/SSN: 12. Company Phone 13. Has a license been obtained from Wyoming uniform credit code? Yes No 14. License 15. Date Received: 16. Expiration Date: IF PARTNERSHIP OR CORPORATION, LIST NAME & ADDRESS (ES) 17. Name/Title: Address (City/State/ZIP): 18. Name/Title: Address (City/State/ZIP): 19. Name/Title: Address (City/State/ZIP): 20. Name/Title: Address (City/State/ZIP): ---PAGE BREAK--- Page 2 of 3 21. Have you, any partner, or corporation ever been convicted of a felony or violation of the laws of the state of Wyoming relating to stolen property? YES NO 22. If "YES", state name of person & felony. I hereby certify the above information to be true and correct to the best of my knowledge. I understand that you may deny or revoke my application if the information is false. I hereby authorize you to check all the above information in processing this application. SIGNATURE OF APPLICANT DATE OF APPLICATION STATE OF WYOMING ) ) COUNTY OF CONVERSE ) Before me personally appeared as of Douglas (Name) (Title) Pawn Brokers, known to me to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein expressed this day of (Day) (Month) (Year) Witness my hand and official seal. (Seal) NOTARY PUBLIC TO BE COMPLETED BY CITY CLERK Date Received: Date of Council meeting: Feb. 8, 2016 License # issued: License Fee (Renewal): $250.00 Receipt Term of License: March 1, 2016 – Feb. 28, 2017 SIGN ---PAGE BREAK--- Page 3 of 3 ****STAFF COMMENTS**** CITY ADMINISTRATOR: ADMINISTRATIVE SERVICES DIRECTOR: CHIEF OF POLICE: PUBLIC WORKS DIRECTOR: COMMUNTIY DEVELOPMENT DIRECTOR: CITY CLERK: