CITY OF FALLS CHURCH POLICE DEPARTMENT
Name
I HEREBY AFFIRM THAT I HAVE PERSONALLY FILLED OUT THIS APPLICATION FOR A PRECIOUS
METAL DEALER'S PERMIT, THAT THE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE AND BELIEF, AND THAT I HAVE NOT KNOWINGLY WITHHELD ANY FACTS OR
CIRCUMSTANCES THAT WOULD, IF DISCLOSED, AFFECT MY APPLICATION UNFAVORABLY. I GIVE
THE FALLS CHURCH POLICE DEPARTMENT THE RIGHT TO CHECK WITH FORMER EMPLOYERS AND TO
SECURE ANY ADDITIONAL INFORMATION FROM ANY SOURCE, IF NECESSARY
Email address
Home Address
Home Phone
Date of Birth
M
F
Precious Metal Dealer's Permit Application
Phone Number
Business Address
Yes
Are you the owner of the business?
No
If you are not the owner please list your supervisor
No
Yes
Itinerant Dealer?
No
Yes
Have you ever been convicted of a criminal offense?
If yes, please list the information
below:
Date
Charge
Court/Disposition
Court/Disposition
Charge
Date
List last two places of employment (please include dates worked and supervisor)
1.
2.
Signature
Date
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