Business Application For Annual License As A Dealer In Precious Metals Form (Page 2 of 4) in pdf

Business Application For Annual License As A Dealer In Precious Metals Form Page 2

*For out of State or out of County applicants. The items purchased are required to be located and available for

inspection for five (5) business days after the last day of the sale. The representative must call the Sheriff’s Office

with their contact information to comply with this requirement. These fields are required:

*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 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

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: _____________________________

PLEASE RETURN COMPLETED APPLICATION ALONG WITH A $50.00 CHECK MADE PAYABLE

TO: Mercer County Treasurer

Business Application For Annual License As A Dealer In Precious Metals Form Page 2