Residential Solicitation Application Page 2
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4his or her authority.
P
B.
A
I
.
ART
PPLICANT
NFORMATION
Please complete the following information about the applicant for a master permit or solicitor’s permit, as the
case may be.
.
or a Solicitor’s Permit
1.
Please check whether you are applying for a Master Permit
2.
Name of applicant (including former names or aliases used during the last 10 years):
____________________________________________________________________________________
___________________________________________________________________________________.
3.
Address where all notices are to be sent (if applicant has local address, then address where notice is to
be sent must be local address):
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________.
Master solicitor’s certification.
4.
If the solicitation is to be conducted on behalf of a master solicitor, then the master solicitor shall execute
the following certification:
The undersigned, who is the master solicitor or who is authorized to sign this certification on behalf of the
master solicitor, hereby swears or affirms that no disqualifying factors exist for the master solicitor, its
controlling officers, directors, partners, or members, as the case may be, or for the solicitor who is the
subject of this application.
Signature:
______________________________________
Type or print name:
______________________________________
Title:
______________________________________
Sworn to and subscribed before me this the _____ day of ___________________, 2012.
________________________________________
Notary Public
My commission expires: ___________________
Solicitor’s certification. If the solicitation is not to be conducted on behalf of a master solicitor, then the
5.
solicitor shall execute the following certification:
The undersigned hereby swears or affirms that he or she has no disqualifying factors.
Signature:
_____________________________________
Type or print name:
_____________________________________
Sworn to and subscribed before me this the _____ day of ___________________, 2012.
_________________________________________
Notary Public
My commission expires: ____________________
P
C.
M
S
I
.
ART
ASTER
OLICITOR
NFORMATION
Where solicitation will be conducted on behalf of a master solicitor, please complete the following information
about the master solicitor.
Master solicitor’s name (including any former names or aliases used during the last ten years):
1.
____________________________________________________________________________________
___________________________________________________________________________________.
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