EmailMe Form - Jermyn Borough Application for Solicitation Permit

Name *

First Last

License Number *

Phone

### - ### - ####

State *

Date of Birth *

Place of Birth *

Age *

Height *

Gender

Male

Female

Weight *

Have You Ever Been Arrested or Convicted of a Felony, Misdemeanor, or a Crime of Any Kind? *

Yes

No

Hair Color *

Eye Color

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Employer/Business Name *

Employer Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Business Phone *

### - ### - ####

What Goods or Services Will You Be Soliciting? *

Length of Time Applicant Wishes to Solicit (Max 4 Months) *

Vehicle Year, Make, Model, Color

License Plate #

State

By Checking This Box, I Agree that on behalf of the employer and in consideration of the issuance of such licenses or permit, employer agrees to become liable and responsible for any and all acts of the solicitor while within the Borough, in violation of a law or otherwise.

I Agree

Each Application May Include One Solicitor and One Vehicle *

Solicitor ($100)

Vehicle ($25)