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RlVISII) 1)1/02/15 City of Lafayette PAWNBROKER BUSINESS LICENSE APPLICATION ACcORDING LAFAYETTE MuNicipAl. CODE Ci iAPTER 55 (As MAY RE AMENDED) Applicant Name: Trade Name of Establishment (doing business as): Address of Premise Location: Lafayette, CO 80026 Street Address Business Mailing Address: (if different from above) Street Address City State Zip Code Contact Person(s): Business Telephone: Business Email This application is for the following: New License* License Renewal Change of Corporate Structure Transfer of Location* Modification of Premises* *Zoning Referral Form must be attached as EXHIBIT A “Applicant” is defined as the Legal Name of the Individual or Business Entity that will hold the license, if approved. The Applicant is applying as a: Corporation Partnership Association or Other Limited Liability Corporation Individual (Sole Proprietor) Attach organizational documents as EXHIBIT B An Individual (Sole Proprietor) must submit a Lawful Presence Affidavit form, provided with application packet, as EXHIBIT C City Sales & Use Tax License No.: State Sales Tax License No. Federal Tax Employer Identification Number (FEIN No.) Certificate of Insurance (not less than $50,000) to cover tangible personal property deposited with pawnbroker pursuant to a contract for purchase against damage, loss or destruction. EXHIBIT D Surety Bond in favor of the City of Lafayette, Colorado in the amount of $1,000. EXHIBIT E 1290 S. Public Rd. • Lafayette, Colorado 80026• (303) 665-5588 Fax (303) 665-2153 ---PAGE BREAK--- ASSOCIATED INDIVIDUALS For each individual listed helow, Please provide the lollowing: YOtI MAY ATTACH SIPARATE SHEITS OR AI)I)ITONAL DOCUMENTS IF NECESSARY Written proof that the person is twenty—one years of age or over Two recent Portrait photographs of each person taken within the last six months (2”x D Pawnbroker l-3usiness License History far each person (Separate form provided) ü List of convictions and pleas of nob contender or guilty for any criminal offense except traffic Local individuals must he lingerprinted by the Lafayette Police Department. Out—of—State individuals must provide flngerprint cards from their local police department Corporations / Individual I Partnership Presideiit Naiiie: Phone: Address: Zip Code: Social Security Number: Driver’s License Number: Date of Birth: Vice—Presideiit Name: Phone: Address: Zip Code: Social Security Number: Driver’s I ,iccnse Number: Date of Birth: Secretary Name: Phone: Address: Zip Code: Social Security Number: Drivers License Number: Date of Birth: Treasurer Name: Phone: Address: Zip Code: Social Security Number: Drivers License Number: Date of l3irth: Individual Name: l’hone: Address: Zip Code: Social Security Number: Driver’s License Number: Date of Birth: If more than two Partners please attach separate sheet I’artner Name: Phone: Address: Zip Code: Social Security Number: Drisers liccnse Number: I )ate of Birth: Partner Name: Phone: Address: Zip (‘ode: Social Security Number: Driver’s License Number: Date of l3irth: 2 ---PAGE BREAK--- Fiiiaiieial Inlorniation — Stockholders Slot kholder Nanw: I h me Add ress: lip (‘ode: l’erceit( 01 Stock: I )rivcr’s I iceilse Numher. I)ate 01 Birth: SloekIHIdcr Naiiie: I Iiiie: ,\dihi,s: Lip (ode: I’ercenl 01 Stock: Driver’s License Number: I)i1e of Birth: S(ockImI(Ier Na fir: I’Iione: Addiess: /ip (‘ode: Percent of Stock: I)rivers license Number: I )ate of Birth: PROOF OF OWNERSHIP OR LEGAL POSSESSION Provide proof of ownership or legal possession, or intent of legal possession. Proof must he for a minimum term of one year from the date of the issuance of the license. EXHIBIT F BUILDING PLANS Provide a set of building plans and specifications for interior of premise (for a new license or transfer of location only) EXHIBIT G REGISTERED AGENT (A person other than the applicant, who prepared this application, e.g., an attorney or an accountant) Registered Agent Name: Mailing Address: Telephone No.: Email Address: Signature, Registered Agent APPLICANT AFFIDAVIT ON NEXT PAGE 3 ---PAGE BREAK--- APPLICANT AFFIDAVIT OF ACCURACY I declare under the penalty of perjury that this application, including all accompanying documents, have been examined by me and to the best of my knowledge and belief are true, correct and complete. I also declare that I have been given a copy of Section 55-100 to 55-1 12 of the Lafayette Municipal Code pertaining to Pawnbro[.ers. Authorized Signature Authorized Signature Printed Name and Title Date State of County of Subscribed and sworn before me on by Signature of notarial officer [SEAL] My commission expires: 4 ---PAGE BREAK--- RI VlSI 1)1) i/l)2/2() 15 City of Lafayette ZONING REFERRAL PAWNBROKER BUSINESS LICENSE A’WDING 10 LAFAYETTE MUNICIPAL CODE CHAPTER 55 (As MAY BE AMENDED) Applicant — Complete this Section Only Business Name: Business Address: Type of License applying for: New License D Change of Location Modification of Premises To Be Completed & Signed By City Planning Department Zoning for the property is: Is the property zoned for the type of license applied for? U Yes U No Is the building going to be enlarged? U Yes U No Please address parking issues as part of your review: Comments: Signature: City Development/Zoning Division: Date: Applicant- complete the lust three questions, check appropriate box, and submit this form with a copy of the site pjji of the premises to the Lafayette Planning Development Department Return the signed ftrm with your application to the City Clerk ---PAGE BREAK--- ityof I’I’v’ISII ) 1)1/(12/2(115 Lafayette PAWNBROKER BUSINESS LICENSE HISTORY Nanie: Employment History for the past 10 years: Name of Business Address Position Held Dates of Employment Comments: Pawnbroker’s License History: Fill out this section if the above named person has previously operated in Lafayette, Colorado or any other city in Colorado or State under a pawnbroker license, has had such license revoked or suspended, and the reason thereof. Name Date Jurisdiction of Action Comments: ---PAGE BREAK--- City of Lafayette RIvIsI:I) 01/02/15 AFFIDAVIT CONCERNING CRIMINAL HISTORY PAWNBROKER BUSINESS LICENSE 1, swear or affirm: My date of birth is: I certify that I have not been convicted of any criminal offense (initial) excluding minor traffic offenses of less that eight points but including any traffic offense in which drugs or alcohol were involved. OR I certify that I have been convicted of the following criminal offenses. (initial) List offense, date of conviction, court and case number, and state and county of the court. (Minor traffic offense of less than eight points need not be listed if no alcohol or drugs were involved.) Attach as separate page. Signature 1)ate State of County of Subscribed and sworn to before me on this of (Seal) Notary Public My commission expires: ---PAGE BREAK--- RlVISlJ) 01/02/15 City of Lafayette LAWFUL PRESENCE AFFIDAVIT PAWNBROKER BUSINESS LICENSE FOR INDIVIDUALS (SOLE PROPRIETORS) New License License Renewal I, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as peijury in the second degree under Colorado Revised Statute 18-8- 503 and it shall constitute a separate criminal each time a public benefit is fraudulently received. Signature Date Form of ID Presented: Valid Colorado Driver’s License. Colorado ID card, Military 11), Coast (luard Mariner, or Native American Tribal l)ocurnents are acceptable forms of identification STATE OF COLORAI)O COUNTY OF BOULDER I, Public in and for said County and State, do hereby certify thai on this day of 20, appeared before me in person and executed the above instrument. iN WITNESS THEREOF, I have hereunto set my hand and seal. Notary Public [SEA LI My commission expires: