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Town of Monument Solicitor’s License Application 645 Beacon Lite Rd., Monument CO 80132 [PHONE REDACTED] www.townofmonument.org Applicant Information (all fields required) NAME OF APPLICANT PHONE NUMBER APPLICANT’S ADDRESS CITY STATE ZIP+4 APPLICANT’S DATE OF BIRTH DRIVER’S LICENSE OR STATE-ISSUED ID NUMBER HAS THE APPLICANT BEEN CONVICTED OF ANY FELONY, MISDEMEANOR OR VIOLATION OF MUNICIPAL ORDINANCE EXCLUDING MINOR TRAFFIC VIOLATIONS? CIRCLE YES OR NO. IF YES, STATE THE NATURE OF THE OFFENSE(S) AND THE PENALTY ASSESSED: Company Information (all fields required) 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 AND SERVICES BEING SOLD LENGTH OF TIME FOR WHICH THE RIGHT TO SOLICIT IS REQUIRED (LICENSES WILL BE VALID FOR ONE YEAR FROM ISSUANCE UNLESS EARLIER REVOKED) Required Fees: Solicitor’s License Application Fee ($10 Per Application) Notary Services Per Document) Supplemental Documents: (must provide 1 of the following) Photocopy of Valid Driver’s License Photocopy of State-Issued Identification Date Application Received: Fees received: CHECK _______CREDIT CARD CASH Received By: Town of Monument Business License DATE APPROVED: FOR TOWN USE ONLY ---PAGE BREAK--- Company Information (all fields required) 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 DURING SOLICITATION (REQUIRED) 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 Name of Applicant Signature of Notary Public My Commission Expires: Notary Stamp or Seal