Solicitor Application

SOLICITOR APPLICATION

The following data must be submitted for each solicitor

Name of Applicant:

D.O.B:

Home Address:

City/State:

Social Security #:

Phone #:

Prior address if less than 3 years:

Driver’s License #:

License State:

If soliciting is to be done in the interest of a group, firm or organization

Business/Organization Name:

Business/Organization Address:

Business/Organization Contact Person:

Business/Organization Contact Phone #:

Please describe nature of business or solicitation intentions in detail:

Date of requested soliciting:

Hours requested:

Please list the last three (3) communities (if any) in which you have conducted a solicitation or canvassing operation:

Motor Vehicle Information

Vehicle registration number & state:

Vehicle owner name:

Vehicle owner address:

Criminal History

List date and nature of any criminal conviction within the past five (5) years. (Incomplete or inaccurate answers are grounds for denial of application)

*Please Note: Applicants are required to:

Turn in a copy of a photo ID card (e.g. driver’s license, passport) with this application. Furnish a 1” x 1” Passport-like Photo with this application so that it may be affixed to your Permit. The fee for a new permit and/or a renewal is $10.00 per person. Furnish a check or money-order, with this application, made payable to the “Town of Norfolk."

I, the undersigned applicant, hereby affirm that the information contained in this application is true and accurate, to the best of my knowledge. I understand that failure to submit complete and accurate answers, or failure to submit the required items listed above, may be grounds for a denial of the application

(Signature of Applicant)

Date

Department Use Only

Approved By:

Date

Denied By:

Date

Citizens Request Center

Pam Cartin*

Your First Name*

Your Last Name*

Email*

Phone*

Issue*

Preferred Method of Contact*

Phone

Preferred Method of Contact*

Phone

Services

Forms

All of Town of Norfolk

Solicitor Application

SOLICITOR APPLICATION

Criminal History

*Please Note: Applicants are required to:

Department Use Only

Citizens Request Center