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Solicitor Application For Certificate of Registration

2. City of Roosevelt Business License Division
   255 South State, Roosevelt, Utah 84066 <br> Phone: 435-722-5001 <br> Fax: 435-722-5000

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

4. Issued
   Issued

5. Expires
   Expires

6. Business ID Number

8. Code

   1. N/A

9. Receipt Number

10. Date Recieved
    Date Recieved

12. Solicitor Application Fee

    1. $100

13. Transfer / Renewal Fee

    1. $50

15. Total Due

16. Payment Method

    1. Check
    2. Cash

20. Section One: Business Information
    Complete all lines - enter N/A if an item is not applicable.

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

22. True / Correct Legal Name of Solicitor

23. Contact Phone Number

25. All former names / aliases used by Applicant in last 10 years

27. Business Entity / DBA

28. Commerce Entity Number

30. Applicant - Date of Birth
    Applicant - Date of Birth

31. Applicant State Driver License / ID Card Number

32. Driver License State

34. Utah State Special Event Sales Tax Number (Call 801-297-6303)

36. Applicant Home Address

37. Home Phone Number

39. City

40. State

41. Zip Code

43. Applicant Mailing Address

45. City

46. State

47. Zip Code

49. If different from Applicant, Responsible Party Name

50. Phone Number

52. Address

54. City

55. State

56. Zip Code

58. Address for Notices

60. City

61. State

62. Zip Code

66. Section Two: Items Required with Application

    1. BCI Report less than 180 days old
    2. Waiver for City Enforcement Purposes (sign Section VI)
    3. Any Licenses / permits...required to transact this business
    4. Proof of Identification (one of the following)
    5. Valid State-issued Driver License or Identification Card
    6. Valid Passport issued by the United States
    7. Valid USA Military Identification Card

70. Section Three: Goods or Services Offered

74. Section Four: Written Disclosures

76. I have received and reviewed the disclosure information required by Roosevelt City Residential Solicitation Ordinance No 2007-332.

78. 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.

    1. I agree.
80. Electronic Signature

81. Date
    Date

85. Section Five: Disqualifying Status Questions - Affirm or Deny Each of the Following Statements*
    *Any negative response in section five of this application renders the applicant disqualified from certification*

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

87. I have been criminally convicted for

    1. Felony homicide
    2. Sexual assault of any kind
    3. Physically abusing, sexually abusing, or exploiting a minor
    4. Sale or distribution of controlled substance

88. I have criminal charges currently pending for

    1. Felony homicide
    2. Sexual assault of any kind
    3. Physically abusing, sexually abusing, or exploiting a minor
    4. Sale or distribution of controlled substance

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

    1. A crime of moral turpitude
    2. Violent or aggravated conduct with persons or property

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

    1. Engaging in fraud or intentional misrepresentation
    2. A debt that was non-dischargeable in bankruptcy

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

    1. Yes, I do.

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

    1. Yes, I was.

96. 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.

    1. Yes, I am.

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

    1. Yes, I do.

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

    1. Yes, I am.

103. Section Six: Waiver Statement and Applicant Acknowledgement of Written Disclosures and Disqualifying Status
     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.

     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.

105. 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.

     1. I agree.
107. Electronic Signature

108. Date
     Date

110. Approval of Roosevelt Police Chief

111. Date
     Date

113. City Council Approval

114. City Council Approval

115. City Council Approval

117. City Council Approval

118. City Council Approval

119. Date Approved
     Date Approved

Leave This Blank:


121. 1. Receive an email copy of this form.
122. Email address

     This field is not part of the form submission.

123. Submit

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