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Applicant Information NAME OF APPLICANT PHONE NUMBER APPLICANT’S ADDRESS CITY STATE ZIP+4 APPLICANT’S DATE OF BIRTH VALID DRIVER’S LICENSE OR STATE-ISSUED ID NUMER (photocopy will be made) HAS THE APPLICANT BEEN CONVICTED OF ANY FELONY, MISDEMEANOR OR VIOLATION OF MUNICIPAL ORDINANCE EXCLUDING MINOR TRAFFIC VIOLATIONS? NO YES IF YES: STATE THE NATURE OF THE OFFENSE(S) AND THE PENALTY ASSESSED: Company Information COMPANY NAME COMPANY PHONE APPLICANT’S POSITION WITHIN THE COMPANY COMPANY ADDRESS CITY STATE ZIP+4 DESCRIBE THE NATURE OF THE BUSINESS AND THE GOODS OR SERVICES TO BE SOLD: LENGTH OF TIME FOR WHICH THE RIGHT TO DO BUSINESS IS REQUIRED: (LICENSES WILL BE VALID FOR ONE YEAR PAST ISSUANCE UNLESS REVOKED) SOURCE/SUPPLY OF GOODS/PRODUCTS PROPOSED TO BE SOLD: LOCATION OF GOODS/PRODUCTS AT TIME OF APPLICATION: PROPOSED METHOD OF DELIVERY OF GOODS/PRODUCTS: DESCRIPTION OF VEHICLE(S) TO BE USED: MAKE MODEL YEAR COLOR LICENSE PLATE STATE Applicant Affidavit – TO BE COMPLETED IN THE PRESENCE OF NOTARY PUBLIC STATE OF COLORADO ) ) ss COUNTY OF EL PASO ) I, the undersigned, being a representative of do hereby state the following: I, hereinafter referred to as “Applicant”, affirm under penalty of perjury, that this application has been examined by me; that the statements made herein are made in good faith and, to the best of my knowledge and belief, are true, correct and complete; and that no omissions have deliberately been left out. I understand and authorize the Town Clerk, or designated representative, to conduct a required background investigation through the Colorado Bureau of Investigation. I affirm that I have read, understand and will comply with Monument Municipal Code Chapter 5.56 “Solicitors”; and understand that failure to comply may result in the revocation of the license I am applying for. SIGNATURE OF APPLICANT (MUST BE WTINESSED BY A NOTARY PUBLIC) PRINTED NAME DATE The foregoing instrument was subscribed and sworn to (or affirmed) before me, this day of , by Signature of Applicant Signature of Notary Public My Commission Expires: Notary Stamp or Seal FOR TOWN USE ONLY Required Fees: Solicitor’s License Application Fee ($10 per application) Notary Services per document) Supplemental Documents: Photocopy of valid driver’s license or state-issued identification Date Application Received: Fees received: CHECK ____CREDIT CARD CASH Received By: Town of Monument BUSINESS LICENSE No. DATE APPROVED: Town of Monument Solicitor’s License Application 645 Beacon Lite Rd., Monument CO 80132 [PHONE REDACTED] www.townofmonument.org ---PAGE BREAK---