APPLICATION WILL BE REJECTED AND FEE FORFEITED IF APPLICATION CONTAINS MATERIAL OMISSIONS OR MATERIALLY INACCURATE STATEMENTS.

Similar documents
Village of Island Lake Solicitors Permit

City of Conway, Arkansas Ordinance No. O-15-31

PEDDLERS, SOLICITORS AND TRANSIENT MERCHANTS

SOLICITOR S PERMIT INFORMATION

PEDDLER S PERMIT APPLICATION

PEDDLERS, SOLICITORS AND TRANSIENT MERCHANTS

Chapter 18 PEDDLERS, SOLICITORS AND TRANSIENT MERCHANTS 1 ARTICLE I. IN GENERAL

PEDDLING/HOME SOLICITATIONS LICENSE APPLICATION FOR THE CITY OF NORTH OLMSTED

ARTICLE IV. AUCTIONS, SPECIAL SALES AND SOLICITATIONS * Division 1. Door-to-Door Solicitation

CODIFIED ORDINANCES OF NEW LONDON PART SEVEN - BUSINESS REGULATION CODE. Chap Cable Television. Chap Mechanical Amusement Devices.

1. Prevent undue annoyance of City residents by peddlers, solicitors and canvassers;

TITLE 9 BUSINESS, PEDDLERS, SOLICITORS, ETC. CHAPTER 1 PEDDLERS, SOLICITORS, ETC. 1

CHAPTER V. BUSINESS REGULATIONS

SPALDING COUNTY, GEORGIA 2018-ORD-08 ORDINANCE

APPLICATION FOR PEDDLERS, CANVASSERS & TRANSIENT MERCHANTS

TITLE 9 BUSINESS, PEDDLERS, SOLICITORS, ETC. 1 CHAPTER 1 MISCELLANEOUS

CHAPTER 22. LICENSING; BUSINESSES & SERVICES. Peddlers, Solicitors and Transient Merchants

DIVISION 1. LICENSE GENERALLY

VILLAGE OF PENTWATER 327 South Hancock St, P.O. Box 622-Pentwater, MI (231) FAX (231)

ALPINE TOWNSHIP KENT COUNTY, MICHIGAN ORDINANCE NO AN ORDINANCE TO LICENSE AND REGULATE SOLICITORS, PEDDLERS and TRANSIENT MERCHANTS

PEDDLERS & SOLICITORS

Transient Merchant, Vendors, Peddlers, & Solicitors License

CHAPTER 4: FEES, LICENSES, AND PERMITS 1. GENERAL PROVISIONS 3. VIDEO GAMES AND POOL TABLES 4. OTHER FEES AND CHARGES 5. FRANCHISE AGREEMENTS

City of Stephenville Solicitation Guidelines for Citizens and Applicants

CHAPTER 10 TRANSIENT MERCHANTS, PEDDLERS, CANVASSERS, PAWN BROKERS AND PRECIOUS METAL DEALERS

TRANSIENT MERCHANT LICENSE APPLICATION

CITY OF UNIVERSITY PARK UNIVERSITY PARK, TEXAS APPLICATION FOR SOLICITOR S PERMIT

ORDINANCE #59 REPEALED BY ORDINANCE #124

CITY OF STURGIS TITLE 31-1

ALGOMA TOWNSHIP KENT COUNTY, MICHIGAN

Chapter 5 AUCTIONEERS, HAWKERS AND PEDDLERS ARTICLE 1 Auctioneers 5-1. Certain sales prohibited. 5-2 License required for auctions; application;

GENERAL LICENSE APPLICATION CITY OF FREEPORT, ILLINOIS

ORDINANCE # BOROUGH OF ROSELAND COUNTY OF ESSEX, STATE OF NEW JERSEY

Chapter 138 PEDDLERS, SOLICITORS AND ITINERANT MERCHANTS

CITY OF SHAMOKIN NORTHUMBERLAND COUNTY, PENNSYLVANIA ORDINANCE NO

TOWN OF WESTERLO. BE IT ENACTED by the Town Board of the Town of Westerlo as follows:

PUBLIC HEARING. The City Attorney makes the following recommendations:

CHAPTER 6 PEDDLERS AND SOLICITORS. Article I. In General. Article II. Licenses. Article I. In General

CHAPTER 5 CONDUCT ARTICLE I CURFEW ARTICLE II NOISE ARTICLE III NUISANCE ARTICLE IV SOLICITATION 5-1

CITY OF ARKANSAS CITY, KANSAS APPLICATION FOR PRIVATE PREMISES LICENSE

ORDINANCE NO OR- ( BEFORE THE JEFFERSONVILLE COMMON COUNCIL STATE OF INDIANA

SUPERIOR CHARTER TOWNSHIP WASHTENAW COUNTY, MICHIGAN ORDINANCE NO. 189

TITLE 9 BUSINESS, PEDDLERS, SOLICITORS, ETC. CHAPTER 1 SOLICITORS, PEDDLERS, ETC. 1

ARTICLE VI. SECONDHAND GOODS DEALERS DIVISION 1. GENERALLY

TOWNSHIPOF MARPLE ORDINANCE No

Chapter 26 Public Peace & Good Order Page 1 of 13

ARLINGTON COUNTY CODE. Chapter 30 PEDDLERS, VENDORS AND CANVASSERS

GREEN OAK CHARTER TOWNSHIP ORDINANCE NUMBER

CHRISTMAS TREE LICENSE

PEDDLER LICENSING AND CONTROL ORDINANCE TOWNSHIP OF GRAND HAVEN, MICHIGAN ord. no. 461 eff. Dec. 22, 2008

Chapter 180 PEDDLING AND SOLICITING

Subchapter 4.14: BINGO GAMES

CHAPTER 12 LICENSES AND PERMITS

9.15 PAWN SHOPS, SECONDHAND STORES, SECONDHAND JEWELRY DEALERS. 74

TITLE 9 BUSINESS, PEDDLERS, SOLICITORS, ETC. 1 CHAPTER 1 MISCELLANEOUS

New Britain Police Department

4-1 TITLE 9 BUSINESS REGULATIONS 4-1

TOWN OF SCHROON Local Law No. 1 of the Year 1977 Regulation of Hawkers, Peddlers and Solicitors LAW

PAHRUMP TOWN ORDINANCE NO. 35

CHAPTER 15 PAWN SHOPS

TITLE 8 ALCOHOLIC BEVERAGES1

Be it enacted by the General Assembly of the Commonwealth of Kentucky: Section 1. KRS is amended to read as follows:

APPLICATION FOR SECOND HAND DEALER LICENSE

Submit photograph of applicant (must be at least 2 x 2 ). Attach photo to application on page provided.

PROCEDURES FOR SOLICITOR'S LICENSE (The procedure outlined herein does not apply to Non-Profit, Charitable Solicitors.)

114.03: PROHIBITION ON SOLICITATION FOR COMMERCIAL PURPOSE

CHAPTER 2. Liquor Licenses and Permits

The City of Chamblee, GA Door-To-Door Salesman Permit Application

**PERMITS GENERALLY ISSUED ON THE FOLLOWING BUSINESS DAY UPON RECEIPT OF COMPLETED APPLICATION**

ORDINANCE NO

REGULATION OF BUSINESS AND VOCATIONS

CHAPTER 755 Secondhand Dealers

CHAPTER 162. History: Adopted by the Board of Selectmen of the Town of Pembroke on February 19, Updated 5/5/14.

ARTICLE 62 POLICE DEPARTMENT ISSUED PERMITS AND LICENSES

ORDINANCE ITINERANT BUSINESS means a dealer who conducts business intermittently within the municipality or at varying locations.

ORDINANCE NO The Common Council of the City of Greenfield do ordain as follows:

Boise Municipal Code. Chapter 5-17 PAWNBROKER'S OR JEWELRY AUCTIONS

CHAPTER 6 BUSINESSES Article 1. Cemeteries. Article 2. Dance Halls. Article 3. Mobile Homes.

Ordinance no. ARTICLE VI. DEALERS IN PRECIOUS METALS AND GEMS, PAWNBROKERS, PAWNSHOPS AND SCRAP METAL PROCESSOR

CHAPTER 64B: SECONDHAND DEALERS

TITLE FIVE - Consumer Protection

CHAPTER 7 LICENSES AND PERMITS

Chapter 4 - AMUSEMENTS

Ordinance No CHAPTER 5.36: PAWNBROKERS, SECONDHAND DEALERS, AND GEMS AND PRECIOUS METALS DEALERS

AN ORDINANCE. Sponsor: Mayor Ronald Krueger From: Licensing Committee THE COMMON COUNCIL OF THE CITY OF WATERTOWN DOES ORDAIN AS FOLLOWS:

CHAPTER 9 BUSINESS CODE (Revised Ord. 1175/05-17)

PROCEDURE FOR OBTAINING A PERMIT TO SELL BEER IN THE CITY OF BRISTOL TENNESSEE

Instructions for Beer Permit Applicants

Offering merchandise for sale on or near public property prohibited Exceptions.

NEW MINNESOTA Automated Pawn System JURISDICTIONS

Title 8 COMMERCIAL LAW AND CONSUMER PROTECTION. Chapter 19A ALABAMA TELEMARKETING ACT.

Special licenses authorized.

TOWN OF NEW HAMPTON, NH HAWKERS, PEDDLERS, AND VENDORS LICENSING ORDINANCE

Village of Suamico. Chapter 5 LICENSES AND PERMITS ORDINANCE

ICE CREAM VENDORS LICENSE

CITY OF CUYAHOGA FALLS

Tennessee Athlete Agent Application for Registration or Renewal

SHENANDOAH POLICE DEPARTMENT WRECKER OPERATOR LICENSE APPLICATION CHECKLIST

Title 5. Licenses and Regulations

Boise Municipal Code. Chapter 5-16 PAWNBROKERS

Transcription:

APPLICATION TO CONDUCT SALES AND PURCHASES** IN THE CITY OF BROOKFIELD THE LICENSE FEE IS $200 HOTEL OR $200 TRANSIENT/PRECIOUS METALS *(Application must be received in our office 2 weeks before the event) **NOTE: FOR HOTEL TRANSIENT MERCHANTS A SECONDHAND PRECIOUS STONES/METALS APPLICATION MUST ALSO BE COMPLETED WITH AN ADDITIONAL $200.00 FEE** THE POLICE DEPARTMENT WILL CONDUCT A RECORDS CHECK THERE IS A FEE OF $12 FOR EACH RECORDS CHECK APPLICATION WILL BE REJECTED AND FEE FORFEITED IF APPLICATION CONTAINS MATERIAL OMISSIONS OR MATERIALLY INACCURATE STATEMENTS. NAME OF ORGANIZATION ADDRESS OF ORGANIZATION PHONE # (+ AREA CODE) DESCRIPTION OF GOODS OR SERVICES OFFERED DATE OF SALE/S PLACE OF SALE/S OWNER/LEAD SUPERVISOR FOR THIS AREA NAME FIRST M.I. LAST MAIDEN DATE OF BIRTH SOCIAL SECURITY NO. HOME ADDRESS PHONE # (+AREA CODE) PLACE WHERE APPLICANT CAN BE CONTACTED FOR AT LEAST 7 DAYS AFTER LEAVING BROOKFIELD PHONE # (+ AREA CODE) HAS A SIMILAR LICENSE BEEN ISSUED TO YOU IN WISCONSIN? IF SO, LIST THE COMMUNITIES WHERE YOU HAVE CONDUCTED SALES WHAT OTHER COMMUNITIES HAVE YOU OPERATED IN WITHIN THE LAST 6 MONTHS? (Outside of Wisconsin)

DO YOU CURRENTLY HOLD AN AUCTIONEERS LICENSE IN THE STATE OF WISCONSIN? DESCRIPTION OF VEHICLES TO BE USED: Make Model Year License No. NAMES OF INDIVIDUAL SOLICITORS CONDUCTING SALES AND PURCHASES IN THE CITY OF BROOKFIELD FEE: $12.00 EACH INDIVIDUAL RECORD CHECK BY THE CITY OF BROOKFIELD POLICE DEPARTMENT First Name M.I. Last Name Maiden Name Home Address City, State, Zip Drivers License # Date of Birth Social Security # Phone # LIST ANY CONVICTION IN THE PAST 5 YEARS, OR PENDING CHARGES FOR OFFENSES RELATED TO THEFT, BURGLARY, POSSESSION OF STOLEN PROPERTY, OTHER CRIMES RELATED TO PROPERTY OR ANY OFFENSES RELATED TO BODILY HARM. IF NONE, WRITE N/A OR NONE. Charge Location/Date Disposition Charge Location/Date Disposition Charge Location/Date Disposition (Use additional sheets if necessary)

READ CAREFULLY BEFORE SIGNING: I declare under penalty of law that all of the above information is true and correct to the best of my knowledge and belief. I understand that incompletes or incorrect information may lead to denial of this license. Date Signature of Applicant SUBSCRIBED AND SWORN TO BEFORE ME this day of, 20. Notary Public/City Clerk

Chapter 5.36 TRANSIENT MERCHANTS, PEDDLERS AND SOLICITORS 5.36.010 Purpose. This chapter is intended to protect against criminal activity, including fraud and burglary, to minimize the unwelcome disturbance of citizens and the disruption of privacy and to otherwise preserve the public health, safety and welfare by regulating, controlling and licensing door-to-door solicitors and peddlers as well as other transient merchant trade. The regulations contained in this chapter are not intended to regulate speech by any person, but merely regulate the activities of those individuals selling or offering for sale merchandise or requesting contributions for a charitable purpose. It shall be unlawful for any direct seller, transient merchant, or charitable solicitor to engage in sales and solicitation within the city without being registered for that purpose as provided herein. (Ord. 1574 1(1), 1996) 5.36.020 Definitions. As used in this chapter: "Charitable organization" means any patriotic, philanthropic, social service, welfare, benevolent, educational, civic, cultural, religious or fraternal, person, partnership, association or corporation. "Contributions" means and includes alms, food, clothing, money, property, financial assistance or other thing of value. A contribution, as defined herein, shall also include a sale or offer to sell any book, card, magazine, membership, merchandise, subscription, ticket or other thing in connection with which an appeal is made of any charitable or religious purpose. "Direct seller" means any individual who, for him/herself, or for a partnership, association or corporation, sells goods or services, or takes sales orders for the later delivery of goods or services, at any location other than the permanent business place or residence of the individual, partnership, association or corporation, and shall include, but not be limited to, peddlers, solicitors and transient merchants. The sale of goods includes donations or contributions, whether direct or indirect, required by the direct seller for the retention of goods by a donor or prospective customer. "Merchandise" means and includes personal property of any kind, and shall include merchandise, goods or materials provided incidental to services offered or sold. The sale of merchandise includes donations required by the seller for the retention of goods by a donor or prospective customer. "Permanent merchant" means a direct seller who, for at least one year prior to the date of the application of this chapter to the merchant: 1. Has continuously operated an established place of business in the local trade area which includes the greater metropolitan Milwaukee trade area; 2. Has established residence in the local trade area which includes the greater metropolitan trade area. "Person" means any individual, firm, partnership, corporation, company, association, church, religious sect, religious denomination, society, organization or league, or one purporting to be. "Solicit" and "solicitation" means and includes any one or more of the following: 1. Selling or offering for sale, or taking or attempting to take orders for the sale of goods or services of any kind, character or description; 2. Selling or offering for sale, or taking or attempting to take orders for books, magazines, periodicals, newspapers and every other type or kind or publication; 3. Requesting, directly or indirectly, contributions on the plea or representation that such contributions will be used for a charitable or religious purpose. "Street vendor" means any person who publicly displays, exposes for sale or offers for sale any goods or services from, upon or in any vehicle, nonpermanent structure or in the open, upon any property of which he is not the legally permitted occupant, including public property.

"Transient merchant" means any person who engages in the retail sale of merchandise at any place in this city temporarily and who does not intend to become and does not become a permanent merchant of this city. (Ord. 1574 1(2), 1996) 5.36.030 Exemptions. The following shall be exempt from all provisions of this chapter: A. Any person delivering to regular customers on established routes; B. Any person selling merchandise at wholesale to dealers in such merchandise; C. Any person selling agricultural products which the person has grown; D. Any person holding a sale required by statute or by order of any court and any person conducting a bonafide auction sale pursuant to law; E. Any person who has an established place of business where the merchandise being sold is offered for sale on a regular basis, and in which the buyer has initiated contact with, and specifically requested, a home visit by the person; F. This chapter does not apply to transient merchants while doing business at special events authorized by the common council; G. Any person exempt by Section 440.51 of the Wisconsin Statutes (statewide peddlers license for veterans); H. Any person selling or offering for sale on behalf of a nonprofit organization sponsored by or affiliated with an athletic sport or public or parochial school. The exemption would apply but not be limited to the following organizations; Girl Scouts, Boy Scouts, Elmbrook Swim Club, Brookfield Soccer Association, etc. (Ord. 1574 1(3), 1996) 5.36.040 Claims of exemption. Any person claiming to be legally exempt from the regulations set forth in this chapter, or from the payment of a permit fee, shall cite to the city clerk the statute or other legal authority under which exemption is claimed and shall present the city clerk proof of qualification for such exemption. (Ord. 1574 1(8), 1996) 5.36.050 Regulation of direct sellers and solicitors. A. Permit Required. No direct seller or solicitor shall engage in such business within the city without first receiving a permit. B. Application for a Permit. An applicant for permit under this section shall file with the city clerk, a sworn application, in writing, on a form provided by the city clerk which shall require the necessary information from the applicant as the city clerk police department shall require for the effective enforcement of this section and the safeguarding of the residents of the city from fraud, misconduct or

abuse. C. Permit Fee. At the time the application is filed with the clerk's office, the applicant shall pay a fee to cover the cost to the city of processing the application and investigating the facts stated therein. The permit fee shall be nonrefundable. A permit fee of two hundred dollars ($200.00) for each business or organization filing an application shall be collected. Charitable solicitors shall not be required to pay the two hundred dollars ($200.00) permit fee, however, proof of tax exempt status must be furnished to the city clerk. 1. An additional fee shall be collected from each business or organization filing an application to cover the costs of a records check for each solicitor. This fee will be charged to all solicitors, charitable or otherwise, and shall include actual costs associated with the records check. The fee shall be due at the time of application and shall be nonrefundable. 2. The permit shall be granted for a period not to exceed thirty (30) days for door to door solicitation with one thirty (30) day administrative extension. The fee of two hundred dollars ($200.00) for hotel sales will cover a period of one year or not more than four sale periods, whichever comes first. A sales period cannot exceed three consecutive calendar days. Solicitors requesting permits for hotel sales need to identify the sale dates to the clerk's office. The fee of two hundred dollars ($200.00) for ice cream vendors shall be granted for a period not to exceed May through September. 3. Ice cream vendors and other solicitors operating from a moving vehicle will need to show proof of liability insurance with a minimum limit of three hundred thousand dollars ($300,000.00). D. Investigation/Disapproval. Upon receipt of the permit and solicitation fee, the city clerk may refer the application to the chief of police or his designee who shall complete an investigation of the statements made in such application as deemed necessary to ensure the protection of the public health, safety and general welfare. The chief of police or his designee, shall report his findings upon the application. The city clerk shall issue or deny the permit in accordance with those findings. The city clerk may refuse to issue a permit to the applicant under this chapter for any of the following reasons: 1. The location and time of solicitation or peddling would endanger the safety and welfare of the solicitors, peddlers or their customers; 2. An investigation reveals that the applicant falsified information on the application; 3. Within the last five years, the applicant has been convicted of a felony, misdemeanor or ordinance violation involving offenses relating to theft, burglary, possession of stolen property, other crimes related to property or any offenses related crimes against life and bodily security, public health and safety, sexual morality, children and the public peace or any offense which relates to the licensed activity; 4. The applicant has been denied a permit under this chapter within the immediate past year, unless the applicant can and does show to the satisfaction of the city clerk that the reasons for such earlier denial no longer exist. An applicant who has properly supplied all pertinent information, and who is approved, shall be issued a direct sellers/solicitation permit. Each solicitor must carry a copy of their license while soliciting in the city. E. Appeal. The application's disapproval and the reasons for disapproval shall be noted on the application, and the applicant shall be notified that his application is disapproved and that no permit will be issued. Notice shall be mailed to the applicant at the address shown on the application form, or at the applicant's last known address. Any person denied a license may appeal the denial through the legislative and licensing committee of the common council. The city clerk must be notified by the person requesting an appeal. If the

application is denied, the license fee will not be refunded. (Ord. 1973-04 1, 2004: Ord. 1734 3 (part), 2000; Ord. 1574 1(4), 1996) 5.36.060 Prohibited practices. The direct seller, charitable solicitor and permanent merchant shall be prohibited from: A. Calling at any dwelling or other place between the hours of eight p.m. and nine-thirty a.m. except by appointment; B. Calling at any dwelling or other place where a sign is displayed bearing the words "No Peddlers," "No Solicitors" or words of similar meaning; C. Calling at the rear door of any dwelling place; or remaining on premises after being asked to leave by the owner, occupant or any other person having authority over such premises; D. Making false, deceptive or misleading statements concerning the quality, quantity or character of any goods offered for sale, the purpose of their visit, or identity of the organization being represented; E. Not more than two individuals shall engage in direct selling or solicitation upon any premises for the same goods or services or for the same religious or charitable purposes; F. No transient merchant, permanent merchant or charitable organization shall make any loud noises to attract customers that can be heard outside the radius of one thousand (1,000) feet; G. No direct seller or charitable solicitor shall solicit or conduct business with persons in motor vehicles upon a road, street or alley, as defined by Section 340.01(22) in the Wisconsin State Statutes; H. No ice cream vendor or solicitor operating from a moving vehicle shall continue sales during the hours of darkness as defined in Wisconsin State Statutes 340.01(23). I. Permits are not valid for use on January 1st, the Thursday prior to Easter through Easter, the Thursday of Thanksgiving through the Sunday following, and December 24th, 25th, 26th and 31st. (Ord. 2014-05 1, 2005; Ord. 1574 1(5), 1996) 5.36.070 Disclosure requirements. A. After the initial greeting and before any other statement is made to a prospective customer, a direct seller, permanent merchant or charitable organization shall expressly disclose their name, the name of the company or organization they are affiliated with, if any, and the identity of merchandise or services they offer to sell or purpose for the solicitation. B. If any sale of merchandise is made by a direct seller, permanent merchant, or charitable organization or any sales order for the later delivery of merchandise is taken by the seller, the buyer shall have the right to cancel the transaction if it involves the extension of credit or is a cash transaction of more than twenty-five dollars ($25.00), in accordance with the procedure as set forth in Section 423.203, Wisconsin Statutes, the seller shall give the buyer two copies of a typed or printed

notice of that fact. Such notice shall conform to the requirements of Sections 423.203(1)(a), (b) and (c), (2) and (3), Wisconsin Statutes. C. If the direct seller, permanent merchant, or charitable organization takes a sales order for the later delivery of merchandise, they shall, at the time the order is taken, provide the buyer with a written statement containing the terms of the agreement, the amount paid in advance, whether full, partial or no advance payment is made, the name, address and telephone number of the seller, the delivery or performance date and whether a guarantee or warranty is provided and, if so, the terms thereof. (Ord. 1574 1(6), 1996) 5.36.080 Revocation. A permit may be revoked by the city clerk if the permittee made any material omission or materially inaccurate statement in the application for registration, made any fraudulent, false, deceptive or misleading statement or representation in the course of engaging in direct sales, violated any provisions of this chapter or was convicted of any crime or ordinance or statutory violation which is directly related to the registrant's fitness to engage in direct selling. The permit may also be revoked if the permittee conducts peddling or solicitation activities contrary to the provisions contained in the permit or in such a manner as to create a public nuisance, constitute a breach of the peace or endanger the health, safety or general welfare of the public. Notice of such revocation and the reason or reasons therefor, in writing, shall be immediately served personally upon the person named in the application, or by mailing the same to the permit holder at the named premises, and by filing a copy of such notice with the city clerk. Appeal from revocation shall be made to the legislative and licensing committee within thirty (30) days of the date of revocation. (Ord. 1734 3 (part), 2000; Ord. 1574 1(7), 1996)

CITY OF BROOKFIELD SECONDHAND PRECIOUS STONES/METALS APPLICATION Applicant License Fee: $200.00 Individual/Employee (over 1) Background Check Fee: $12.00 (License valid January to December) Instructions: Please check one Individual License (Complete Sections 1,2,6,7) Partnership License (Complete Sections 1,2,3,6,7) Limited Liability Corporation (Complete Sections 1,2,4,6,7) Corporate License (Complete Sections 1,2,5,6,7) Applicant/Proprietor Name (Last, First, MI): SECTION 1 APPLICANT INFORMATION Residence City, State, Zip: Date of Birth: Place of Birth: Driver s License #: SECTION 2 BUSINESS INFORMATION Business Business Owner/Proprietor City, State, Zip: Business Phone #: Fax #: Email: SECTION 3 PARTNERSHIP INFORMATION Partnership Names & Address of all members: (Attach additional sheets if necessary)

Limited Liability Corporation Names & Address of all members: SECTION 4 LIMITED LIABILITY CORPORATION (Attach additional sheets if necessary) SECTION 5 CORPORATION Corporation Where incorporated (what state): Names & Address of all officers and directors: (Attach additional sheets if necessary) SECTION 6 OFFENSE/CONVICTION RECORD Has applicant, including an individual, agent, officer, director, member, partner, manager, or proprietor been convicted of any crime, statutory violation punishable by forfeiture, or county or municipal ordinance violation. If so, explain, or if none, write n/a or none. Disposition: Disposition: Disposition: Offense: Offense: Offense: Has applicant, including an individual, agent, officer, director, member, partner, manager, or proprietor ever used or been known by a name other than the applicant s name. If so, list name(s) used and give information concerning dates and places used. (Attach additional sheets if necessary)

Has applicant, including an individual, agent, officer, director, member, partner, manager, or proprietor ever been denied or had revoked or suspended a pawnbroker, secondhand article dealer or secondhand jewelry dealer license from any governmental unit. If so, list date, location, and reason for the action. Date: Location: Reason: Date: Location: Reason: Date: Location: Reason: Date: Location: Reason: READ CARFULLY BEFORE SIGNING: I declare under penalty of law that all of the above information is true and correct to the best of my knowledge and belief. I understand that incomplete or incorrect information may lead to denial of this license. Date: Signature of Applicant: SUBSCRIBED AND SWORN TO BEFORE ME this day of, 20. Notary Public/City Clerk

SECTION 7 INDIVIDUAL/EMPLOYEE PERSONAL INFORMATION FEE: $12.00 EACH INDIVIDUAL/EMPLOYEE FOR A RECORD CHECK BY THE CITY OF BROOKFIELD CITY CLERK S OFFICE & POLICE DEPARTMENT PLEASE PRINT First Name M.I. Last Name Maiden Name Home Address City, State, Zip Drivers License # Date of Birth Social Security # Phone # LIST ANY CONVICTION IN THE PAST 5 YEARS, OR PENDING CHARGES FOR OFFENSES RELATED TO THEFT, BURGLARY, POSSESSION OF STOLEN PROPERTY, OTHER CRIMES RELATED TO PROPERTY OR ANY OFFENSES RELATED TO BODILY HARM. IF NONE, WRITE N/A OR NONE. Offense: Disposition: Offense: Disposition: Offense: Disposition: (Use additional sheets if necessary) READ CAREFULLY BEFORE SIGNING: I declare under penalty of law that all of the above information is true and correct to the best of my knowledge and belief. I understand that incompletes or incorrect information may lead to denial of this license. Date Signature of Applicant SUBSCRIBED AND SWORN TO BEFORE ME this day of, 20. Notary Public/City Clerk