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Solicitor Application For Certificate of Registration

  1. 255 South State, Roosevelt, Utah 84066
    Phone: 435-722-5001
    Fax: 435-722-5000

  2. Complete all lines - enter N/A if an item is not applicable.

  3. Section Two: Items Required with Application

  4. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  5. *Any negative response in section five of this application renders the applicant disqualified from certification*

  6. I have been criminally convicted for

  7. I have criminal charges currently pending for

  8. I was criminally convicted of a misdemeanor in last five years involving

  9. I have a Final Judgement entered against me in the last 5 years for

  10. I have had a criminal felony conviction within last ten years.

  11. I was incarcerated in federal or state prison in last five years.

  12. I am now on parole / probation to any court, penal institution, or government entity including being under house arrest or subject to a tracking device.

  13. I have an outstanding arrest warrant from any jurisdiction.

  14. I am now subject to a protective order for physical or sexual abuse.

  15. I, the undersigned, do hereby verify, under penalty of perjury, that the information provided herewith is complete, truthful and accurate to the best of my knowledge and belief. I do hereby agree to allow the City to obtain a name/date of birth BCI background check for enforcement purposes of Roosevelt City Residential Solicitation Ordinance No2007-322. I agree to conduct business in complete accordance with all laws, ordinances, and regulations governing operation of such business. I acknowledge that soliciting without a valid certificate in plain view may result in revocation of such and/or citation. I understand that once the certificate of registration is issued, it becomes invalid if any of the application information changes, and a new application will be required to update the information on record.

  16. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  18. This field is not part of the form submission.