Individual Application For Annual License As A Dealer In Precious Metals Form printable pdf download

Individual Application For Annual License As A Dealer In Precious Metals Form

Individual Application

License #__________

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF MERCER

OFFICE OF THE SHERIFF

Individual application for Annual License as a Dealer in Precious Metals

APPLICANT’S FULL NAME: __________________________________________________________________

DRIVER’S LICENSE #: ________________________________________STATE: ________________________

DATE OF BIRTH: ________________ SOCIAL SECURITY # ____________________ AGE: _____SEX_____

ADDRESS: _________________________________________________________________________________

TELEPHONE #: ________________________ CELLULAR #: ________________________________

APPLICANT’S BUSINESS ADDRESS: __________________________________________________________

*LOCATION OF SALE: ______________________________________________________________________

*DATE(S) OF SALE: _________________________________________________________________________

*CONTACT NAME AND PHONE #_____________________________________________________________

*COPY OF CONTACT’S DRIVER’S LICENSE MUST BE ATTACHED TO THE APPLICATION

HAVE YOU EVER BEEN INDICTED OR CONVICTED OF A CRIME?

_____Y _____N

HAVE YOU EVER HAD AN APPLICATION FOR A PRECIOUS METALS DEALER OR LICENSE

REJECTED, SUSPENDED, CANCELLED, OR REVOKED BY ANY AGENCY?

____Y_____N

HAVE YOU OBTAINED ALL REQUIRED MUNICIPAL PERMITS & LICENSES?

____Y_____N

HAVE YOU OBTAINED A SCALE CERTIFICATION FROM THE DEPT OF AGRICULTURE? ____Y_____N

WILL THE ITEMS BE AVAILABLE FOR INSPECTION 5 DAYS AFTER YOUR PURCHASE? ____Y_____N

HAVE YOU READ AND UNDERSTAND YOUR RESPONSIBILITIES AS A LICENSEE?

____Y_____N

*For out of State or out of County applicants. These fields are required.

I verify the facts set forth in this application are true and correct to the best of my knowledge, information and belief. This verification is made

subject to the penalties of Section 4904 of the PA Crimes Code (18 Pa. C.S. 4904) relating to unsworn falsification to authorities.

APPLICANT’S SIGNATURE _________________________ DATE OF APPLICATION ____________________

SHERIFF’S OFFICE USE ONLY:

BACKGROUND CHECK ________________________________________________________________

________________________________________________________________

DATE: _____________________ BY: _________________________________

Individual Application For Annual License As A Dealer In Precious Metals Form