DEPARTMENT OF POLICE
SOUTHINGTON, CONNECTICUT 06489

APPLICATION FOR VENDORS LICENSE

DATE: ______________________

NAME: _____________________________________________________

ADDRESS: ____________________________________________________________________

(STREET) (CITY/TOWN) (STATE)

DATE OF BIRTH: _______________ SEX: ________ S.S.N. _____________________

HEIGHT ___________ WEIGHT ___________ HAIR _______ EYES _______ RACE ______

PHONE: (______) _________________

VEHICLE REGISTRATION NUMBER: ________________________

DESCRIPTION OF VEHICLE TO BE USED: _________________________________________________________

CONNECTICUT STATE TAX ID NUMBER: ______________________________________

BUSINESS NAME: _____________________________________ BUSINESS PHONE: (_____) _____________

BUSINESS ADDRESS:______________________________________________________________________

(STREET) (CITY/TOWN) (STATE)

TYPE OF BUSINESS OR GOODS FOR SALE: ___________________________________________________

_______________________________________________________________________________________

Your signature below, authorizes the Southington Police Department to conduct a background investigation to determine if you have a criminal or motor vehicle history which may prevent this department from issuing this permit/license. This permit/license may be revoked or refused if the provided information is found to be falsified.

APPLICANTS SIGNATURE: ________________________________________________

---------------------------------------DO NOT WRITE BELOW THIS LINE---------------------------------------

APPROVED:____________________ REJECTED: ______________________

REASON: __________________________________________________________________________

APPROVAL OR REJECTION VERIFIED BY: ____________________________ DATE:_______________________