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Sarpy County Clerk's Office

Peddler & Solicitor License Application

Name:

Alias/Maiden Name:

Date of birth:

SSN:

Phone:

Current Address:

City:

State:*

ZIP Code:*

ZIP Code:

State:

City:

Previous Address:

Email address:*

State license/I.D. was issued:*

Have you ever been convicted of any crime - other than a petty traffic violation?*

Yes No

(If YES ~ explain the nature,date,and location of the offense(s) and the punishment or penalty imposed.)

Applicant Information

Employer Information

Company name:

Company address:*

ZIP Code:*

State:*

City:

Co. phone #:

Supervisor's Name:

Phone #:

Product/Service Information

What product or service are you selling?

Dates and times you will be selling?

List below all areas where you or your company conducted business immediately preceding this application (maximum of 5), including the year that you were in these counties:

Vehicle(s) Information for Proposed Activity

Year, make, model, and color of vehicle(s):

License plate number(s) and state:

Signature/Date

I hereby authorize Sarpy County to have access to all sources of information that may be consulted to verify the information I have provided above. This includes authorization to check criminal history records if I have been asked to provide that information.

Signature of Applicant*

Date

Please attach a copy of your photo ID

State drivers liscense # or state issued I.D.card # OR passport # and visa status if not U.S. citizen: *

This application form requests information which may be classified as private or confidential. This information is required by County Ordinance. Failure to provide accurate information can result in the denial of the license