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CITY OF MIDDLETON Temp. Lic. # OPERATOR LICENSE APPLICATION q New CLASS: q Temporary- $8 License Period: 1-14 q Renewal License Period: Expires Filling out your application: n An Operator License is a priviledge, not a right. Any false answers or omissions may result in the denial of your application. n The City of Middleton will perform a background check to verify that the information you provided is complete and accurate. n This application must be filled out accurately and completely. All fees are non-refundable. n A person is limited to only one temporary operator license in a year. Last Name First Name MI Date of Birth Current Street Address City ST Zip Previous Street Address City ST Zip Home Phone Work Phone Driver's License # ST Current Employer Address Previous Employer Address Establishment where you will use this license Contact Person & Phone Number Since your 17th birthday, have you ever been convicted of a felony or misdemeanor (including criminal traffic offenses). List Below. q Yes q No As a juvenile, were you ever waived into adult court and convicted of a felony or misdemeanor? List Below. q Yes q No Have you ever been cited, ticketed, or arrested for any of the following: operating under the influence, operating with a prohibited q Yes q No alcohol concentration. Offenses related to absolute sobriety, alcohol, identification card, drugs, fraud, identity theft, obstruct/resist/flee/elude/escape police? List Below. List all convictions, citations, tickets, and pending charges. Year Location Charge Disposition I attest that the above information is true and correct and that any false or incomplete information may result in denial of my application. Applicant's Signature Date Filed Amt. Pd. By q Cash q Check q Credit/Debit Mail To Type of Course & Completion Date Permit # PD Determination: q Approved Records Check by: Date: q Denied Notes: Initials (notes) Middleton PD Authorized Signature Date q L&O Appeal Date: q Approved q Denied Determination: