Business Application For Annual License As A Dealer In Precious Metals Form
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4Business Application
License #_________
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF MERCER
OFFICE OF THE SHERIFF
Business application for Annual License as a Dealer in Precious Metals
APPLICANT’S FULL NAME: ___________________________________________________________________
DATE OF BIRTH: ____________________DRIVER’S LICENSE #: _______________________STATE: ______
BUSINESS NAME: ____________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
TELEPHONE # ____________________________ CELLULAR #_______________________________________
IF PENNSYLVANIA CORPORATION, DATE OF INCORPORATION: _____/_____/_____
IF FOREIGN CORPORATION, DATE OF REGISTRATION IN PA: _____/_____/_____
AND
NAME OF STATE IN WHICH INCORPORATED: ________________ DATE: _____/_____/_____
NAMES AND ALIASES OF PARTNERS OR OFFICERS AND BOARD MEMBERS:
(separate page is acceptable)
NAME
ADDRESS
DOB
SEX
SS#
TITLE
1.____________________________________________________________________________________________
2.____________________________________________________________________________________________
3.____________________________________________________________________________________________
HAVE ANY OF THE ABOVE NAMED PARTNERS, CORPORATE OFFICERS, OR MEMBERS OF THE
CORPORATION’S BOARD OF DIRECTORS EVER BEEN INDICTED OR CONVICTED OF A CRIME IN
THIS COMMONWEALTH OR ELSEWHERE?
_____YES _____NO
IF YES, GIVE NAME AND DETAILS: ____________________________________________________________
_____________________________________________________________________________________________
HAVE ANY OF THE ABOVE NAMED PARTNERS, CORPORATE OFFICERS OR MEMBERS OF THE
CORPORATION’S BOARD OF DIRECTORS EVER HAD AN APPLICATION FOR A PRECIOUS METALS
DEALER LICENSE SUSPENDED, CANCELLED OR REVOKED BY ANY FEDERAL, STATE, OR
MUNICIPAL AUTHORITY?
_____YES _____NO
IF YES, GIVE NAME AND DETAILS _____________________________________________________________
_____________________________________________________________________________________________
NAME OF OFFICE MANAGER: _________________________________ PHONE #_______________________
SIGNATURES OF PARTNERS OR OFFICERS:
(1) _____________________________________ DATE:_______________
(2) _____________________________________ DATE:_______________
(3) _____________________________________ DATE:_______________
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