Application For Solicitor Certificate Of Registration (Alsip PD)

Application For Solicitor Certificate Of Registration

To if you would prefer to download this form for printing, please click here
Date*
MM slash DD slash YYYY
Name
First*
Last*
Middle
Home Address*
City/State*
Zip*
Last 3 Years:
Home Address
City/State
Zip
Home Address
City/State
Zip
Home Address
City/State
Zip
Height*
Weight*
Hair*
Eyes*
Sex*
Driver's License No.
State
D.O.B.*
Month
Day
Year
City & State*
Marital Status*
Spouse's Name
Home Phone
Work Phone
Social Security No.
Present Employer
Address
City & State
Yrs. of Employment
Previous Employer
Address
City & State
Yrs. of Employment
Address
City & State
Yrs. of Employment
Name of Supervisor
Phone Number
Describe the type of soliciting you will be doing:*
Soliciting will be residential?*
- Yes
- No
Soliciting will be commercial?*
- Yes
- No
Soliciting will be other
(Describe)
Have you ever been convicted of any provision of this Ordinance or any other Soliciting Ordinance?*
- Yes
- No
Soliciting Ordinance Conviction Description
If you've answered "Yes" to the previous question, please describe:
Have you ever been convicted of any felony or any other State of Federal Law?*
- Yes
- No
Felony/State/Federal Law Conviction Description
If you've answered "Yes" to the previous question, please describe:
Dates of any previous applications:
ANY FALSE MATERIAL STATEMENT IN THIS APPLICATION SHALL BE CAUSE FOR DISQUALIFICATION
Applicant's Signature*
Date*
MM slash DD slash YYYY