APPLICATION FOR PEDDLER'S PERMIT

Name________________________ Date of Birth __________________Date__________________

Home Address____________________________________________________________________

Business Address__________________________________________________________________

Home Phone#__________________________Work Phone#________________________________

Description of Merchandise___________________________________________________________

Method of Distribution_______________________________________________________________

How long are you selling for?__________________________________________________________

Number of solicitors_________________________________________________________________

Names and Addresses of Solicitors______________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Type of Vehicle________________________ Year _____________ Plate_______________________

                    THE UNDERSIGNED:

                    1) ACKNOWLEDGES RECEIPT OF A COPY OF CHAPTER 140 OF THE CODE OF THE TOWN OF

                    HORSEHEADS, "PEDDLING AND SOLICITING" AND AGREES TO ABIDE BY THE RULES AND

                    REGULATIONS OF SAME

                    2)  SWEARS THAT HE/SHE IS A CITIZEN OF THE UNITED STATES, AND NEVER BEEN CONVICTED

                    OF A FELONY OR A MISDEMEANOR

                    3)  GRANTS PERMISSION FOR THE TOWN OF HORSEHEADS TO CONDUCT AN INVESTIGATION

                    FOR FELONY OR MISDEMEANOR CONVICTION.

                                                                                                __________________________________

                                                                                                Signature of Applicant

                Sworn to before me this ____Day of _____20___.

                ______________________________________

                Notary Public                                                                   Fees:  $25.00 for License and one person

                                                                                         $10.00 for each additional person