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Continue to Page 2 CITY OF DUBLIN POLICE SERVICES CHARITABLE SOLICITATION & SALES PERMIT APPLICATION Solicitation and Sales activities permitted between the hours of 9:00AM and 8:00 PM. PRIMARY APPLICANT INFORMATION Name: Last First Middle Aliases Used: Permanent Home Address: City, State, Zip: Home Phone: Cell Phone: Birth Date: Drivers License Number: State: Have you been convicted of any felony or misdemeanor involving injury to person(s) or property, theft, fraud or misrepresentation within the past ten years? Yes No If yes, list each conviction including date, location, charge, court and disposition of the offense: CHARITABLE ORGANIZATION INFORMATION Organization Name: Address: Phone: Fax: Items or Services to be Sold: Length of time for which the right to conduct activity is desired: (Attach additional sheets as necessary.) If applicable, has the California Attorney General issued a permit to the organization for “Commercial Fundraiser for Charitable Purpose” pursuant to Government Code §12599? Yes (If yes, please attach copy.) No ---PAGE BREAK--- CHARITABLE SOLICITATION & SALES PERMIT APPLICATION CONTINUED GROUP APPLICATIONS * Please provide the names of all individuals engaging in activity in conjunction with this permit. Name: Phone: Name: Phone: Name: Phone: Name: Phone: Name: Phone: Name: Phone: Name: Phone: * Provision of this information is mandatory for Non-Dublin residents and individuals engaged in these activities for non-Dublin based organizations. Applicant must also provide copies of state issued identification and/or student body cards for each person listed above. Attach additional sheets as necessary. VEHICLE INFORMATION * Please provide information for any vehicles proposed to be used in conjunction with this permit. Make/Model: Year: License Plate Make/Model: Year: License Plate Make/Model: Year: License Plate * Provision of this information is mandatory for Non-Dublin residents and individuals engaged in these activities for non-Dublin based organizations. Please attach registration information and proof of insurance for each listed vehicle. Provision of vehicle safety information may also be required. Attach additional sheets as necessary. APPLICANT CERTIFICATION I declare under penalty of perjury that the information contained in / or submitted with this application is true and correct. Signature Date Important: Non-Dublin residents and individuals engaged in solicitation and sales activities for non-Dublin based organizations must attach: A letter from the Charitable Purpose organization certifying the applicant’s authority to engage in the conduct of Charitable Solicitor or Salesperson on behalf of the Charitable Purposes organization. Office Use Only: Copy of DL Comm Fundraiser Permit Groups: Copies of ID’s Vehicle Info Ltr from Org 04/07