Peddling & Soliciting License Application Form - East Goshen Township
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1EAST GOSHEN TOWNSHIP
PEDDLING & SOLICITING LICENSE APPLICATION
1580 PAOLI PIKE WEST CHESTER, PA 19380-6199
PHONE (610)-692-7171
FAX (610)-692-8950
(PLEASE PRINT. SUBMIT 2 PHOTOS ( 2 INCHES BY 3 INCHES) TAKEN WITHIN THE LAST SIX MONTHS THAT COMPLY WITH
U.S.PASSPORT STANDARDS
Date: ___________________________
Social Security #: ______________________________
Name: ___________________________________ ________________________________ ________
Last
First
M.I.
Birth Place: _____________________________________
Date of Birth: ____________________
Address: _____________________________________________________________________________
Street Name & Number, P.O. Box and/or Apt #
__________________________________________________________________
City, State & Zip Code
Phone: ______________________________________ _____________________________________
Employed by: ________________________________________________________________________
Address: _____________________________________________________________________________
Street Name & Number, P.O. Box and/or Apt #
__________________________________________________________________
City, State & Zip Code
Phone: ______________________________________ _____________________________________
Business Activity: _______________________________________________
NON-PROFIT: NO YES
State specifically the nature of the business activity in which you wish to engage within the Township.
________________________________________________________________________________________________
________________________________________________________________________________________________
Have you ever been convicted in any jurisdiction of any crime constituting a misdemeanor, felony or summary offense
other than that of minor traffic violations. NO YES and, if so, of what crime or crimes? Describe below
________________________________________________________________________________________________
________________________________________________________________________________________________
Are you currently subject to any court ordered supervision? NO YES and, if so, Describe below
________________________________________________________________________________________________
________________________________________________________________________________________________
I hereby verify and affirm that all the information on the application is true, correct and complete to the best of my knowledge, ability and belief. I
understand that if the application and information has been made with fraudulent intent, I may be guilty of a misdemeanor of the second degree
punishable by a fine up to $ 5,000.00 and/or imprisonment up to two (2) years upon conviction, pursuant to 18 PA C.S.A # 4904 relating to unsworn
falsification to authorities. I understand that East Goshen Township required a criminal history and/or background check prior to the issuance of a
solicitation permit and I hereby give my consent for them to do so. Upon receipt of background check information the Township will redact the
applicants SSN above.
_________________________________________
Signature of Applicant
c:\users\bmccool\appdata\local\microsoft\windows\temporary internet files\content.outlook\5uumsk0c\peddling soliciting license app 07222013.doc
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