Solicitor Permit Application
All fields must be completed.
Applicant Information:
Name (First, MI, Last)
Social Security Number
Date of Birth
lbs.
Driver’s License (DL) Number
DL State
Male/Female
Eye Color
Weight
A color copy of a driver’s licenses is required.
Permanent Address
City
State
Zip Code
Local Address (if different than permanent)
City
State
Zip Code
(
)
Home Phone
(
)
Cell Phone
Email Address
Business Information:
Name of Business
Length of
Service
Business Address
City
(
)
Business Phone
(
)
Business Fax
(
)
Manager’s Cell Phone
Manager’s Name
State
Zip Code
Email Address
Nature of the business and the goods to be sold/distributed:
Website
Vehicle Information: (If a vehicle is used in soliciting/canvassing.)
Vehicle Make
Vehicle Model
Tag Number
State of Issuance
Applicant Agreement and Signature: (Initial each box indicating you have read and understand each statement.)
I swear that I have not been convicted of a felony, misdemeanor, or ordinance violation involving force, violence,
moral turpitude, deceit, fraud, or any other law regulating the act of soliciting or canvassing as defined by the
Shawnee Municipal Code, chapter 5.26, within the past five (5) years within any state of the United States.
I swear that I have not had a solicitation permit or registration revoked or suspended under the ordinances of the
City of Shawnee or any other city.
I understand and agree that if this permit is granted, it will not be used or represented in any way as an
endorsement of the City of Shawnee or any department or officer of the City of Shawnee.
I understand that if this permit is granted, I must adhere to all regulations of the Shawnee Municipal Code, Chapter
5.56, and that if I fail to follow the regulations that I may be subject to fines up to $500 and imprisonment.
I swear that the above is true and accurate information.
Applicant Signature (Must be signed in the presence of a Notary Public.)
Date of Application
Notary Section
Subscribed and sworn to me before this ______ day of _____________, 20______.
My commission expires _______________________________
Signature of Notary Public _____________________________
{Notary Seal}