City of Mukilteo Finance Department
Attn: Business Licenses
11930 Cyrus Way
Mukilteo, WA 98275
(425) 263-8035
croberts@mukilteowa.gov
www.mukilteowa.gov
CANVASSER, PEDDLER & SOLICITOR
FORM A
Business Name: _____________________________________________________________________
Business Contact: ___________________________________________________________________
Contact Phone Number & Email: _______________________________________________________
Canvassing Beginning Date: _______________________Ending Date: _________________________
Under penalty of perjury, I, the undersigned hereby certify that the information provided on this application is true and correct, to the
best of my knowledge, and that the business for which this license is sought will be operated in a lawful manner and will not be in
violation of any federal, state or local law, ordinance or regulation. I understand that all listed individuals may be subject to a criminal
records check.
Signature: _______________________________ Date: _____________________________________
Print Name: ______________________________ Title (if applicable): __________________________
First Name Middle Name Last Name Date of Birth ID Included
ATTACH ADDITIONAL SHEETS IF NECESSARY
The following information is required for each person participating in canvassing, peddling or soliciting
activity, including a legible copy of government issued photo identification.
List specific neighborhoods or areas in which canvassing, peddling or soliciting activity will take place:
FOR OFFICE USE ONLY
Date ________
_______ Fee Paid ______________ BID # ______________ LIC # ________________
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