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APPLICATION FOR PEDDLER/COMMERCIAL SOLICITOR UNDER CHAPTER 804 SLCRO OR

STREET VENDOR’S LICENSE UNDER CHAPTER 812 SLCRO

Please print. All questions MUST be answered. If a question does not apply, write N/A for non-applicable

NAME OF APPLICANT__________________________________________________________________________

FULL First Name

Middle Initial

Last Name

Permanent address of applicant. No post office Box # will be accepted. MUST BE an actual street address:

________________________________________________________________________________________________________

Street Address

City

State

Zip Code

Area Code & Phone #

IF APPLICANT IS FROM OUT OF TOWN give local residence address or hotel name and address. No Post Office Box

# will be accepted, MUST BE an actual street address:

________________________________________________________________________________________________________

Street Address

City

State

Zip Code

Area Code & Phone #

AGE_______ BIRTHDATE_______/______/______ PLACE OF BIRTH__________________________________________

City & State or Country

SEX: M

RACE_______________________SOCIAL SECURITY #_____/_____/______

COLOR OF HAIR___________ COLOR OF EYES______________HEIGHT____ ‘_____” WEIGHT_______

Name of business represented (in St. Louis)___________________________________________________________________

Address__________________________________________________Area Code & Phone#_____________________________

Street address, city, state and zip code

Name of business represented (out of St. Louis)________________________________________________________________

Address__________________________________________________Area Code & Phone#_____________________________

Street address, city, state and zip code

Relationship between business & applicant____________________________________________________________________

PLACE AN X BY THE LICENSE FOR WHICH YOU ARE APPLYING AND ANSWER THE QUESTION:

( ) If applying for a Peddler’s or Street Vendor’s License list the merchandise to be sold:

________________________________________________________________________________________________________

( ) If applying for a Solicitor’s License, what is being solicited:

________________________________________________________________________________________________________

Name(s) of Manufacturer(s)________________________________________________________________________________

Describe your operation___________________________________________________________________________________

(What are you doing that you need this license?)

If a Street Vendor, list year, make & model of your vehicle______________________________________________________

(Street Vendor’s only)

Area of County in which you are Peddling, Street Vending or Soliciting___________________________________________

(permissible only in Unincorporated StLCnty)

Eash license is issued for a period of six (6) months ONLY.

Has applicant ever been convicted of any violation of any Federal, State, County or Municipal Law? _____Yes _____No

If yes, Describe fully_____________________________________________________________________________________

For additional space, use back of application

Punishment or penalty assessed___________________________________________________________________________

For additional space, use back of application

I certify that all answers and statements made on this application and any attachments are true to the best of my knowledge. I agree

and understand that any misstatement of material facts herein is cause for suspension or revocation of this license.

DO NOT SIGN THIS APPLICATION (Signature)____________________________________________________________

UNTIL IN FRONT OF A NOTARY

Subscribed and sworn to before me this _______day of ___________________

My commission expires:

____________________________________Notary Public_________________________________________________

ST. LOUIS COUNTY DEPARTMENT OF REVENUE, DIVISION OF LICENSES

41 S. CENTRAL, CLAYTON, MO 63105 (314) 615-4217

Application For Peddler/commercial Solicitor - St. Louis County Department Of Revenue, Division Of Licenses

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