Direct Shippers Renewal Application Form Page 3
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4Direct Shippers-RENEWAL
dir-ship-renapp.rev-1/17/13
2. Arrest/Conviction Information
Has the applicant or (if partnership) any of the partners, or (if a corporation) any of the officers, directors,
stockholders, or any agent or employee of the applicant, been ARRESTED and/or CONVICTED during this renewal
period (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind
except minor traffic violations?
YES
NO
Previously Reported
If YES, complete the chart below and where applicable, submit a Police Report, Certificate of Disposition, Certificate
of Conviction or a Certificate of Relief from Disabilities from the Court Clerk for each case. If necessary, attach
additional sheets.
Connection with Licensed
Nature of the arrest
Name of the Defendant
Premise
Date of Offense
Disposition
and/or conviction
(licensee, officer)
3. Applicant Information and Certification
The signature below certifies that I know the contents of this application and the statements contained therein; that the
same are true of my own knowledge; and that I am authorized to execute this application and sign this certification. I
further certify that I have read the terms and conditions included with this application for the renewal and agree to comply
with the conditions.
A. Sole Proprietor
(This section must be completed, signed and dated by the sole proprietor.)
Print Name:
Social Security #:
Date of Birth:
Residence street address:
City:
State:
Zip Code:
Telephone # (include area code):
Cell Phone # (include area code):
Signature
Title
Date
B. Partnership
(This section must be completed, signed and dated by each partner.)
Social Security #:
Print Name:
Date of Birth:
Residence street address:
City:
State:
Zip Code:
Telephone # (include area code):
Cell Phone # (include area code):
Partner Signature
Title
Date
Print Form
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