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CITY OF DOUGLAS 2014-2015 PAWNBROKER'S LICENSE APPLICATION INFORMATION REGARDING APPLICANT: Full Social Security Phone (Premises being licensed) (Residence) Drivers license INFORMATION REGARDING COMPANY: Company name: Company Company address: Company phone#( Has a license been obtained from Wyoming uniform credit code? Yes No License No. DATE: Expiration Date: ***IF PARTNERSHIP OR CORPORATION LIST NAME & ADDRESS*** Have you, 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 If "YES", state name of person & felony. ---PAGE BREAK--- 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 ) appeared before me on this day of and upon oath stated that the individual above written and all information contained herein is true, to the best of his/her knowledge, information and belief. Witness my hand and official seal. NOTARY PUBLIC (seal) TO BE COMPLETED BY CITY CLERK Date Received Date of Council meeting LICENSE FEE: Date of Council approval Renewal License # issued New For term: Receipt# ****STAFF COMMENTS**** CITY ADMINISTRATOR ADMINISTRATIVE SERVICES DIRECTOR CHIEF OF POLICE PUBLIC WORKS DIRECTOR PLANNING DIRECTOR CITY CLERK