DIVISION OF POLICE
460 Rocky Fork Blvd.
Gahanna, OH 43230
614.342.4240
SOLICITOR'S PERMIT
Please Print
NAME________________________________________________ DATE______________________________
ADDRESS________________________________________________________________________________
CITY______________________________________ STATE________________ ZIP_____________________
HOME PHONE #____________________________ BUSINESS/CELL #______________________________
SOCIAL SECURITY #________________________________ DATE OF BIRTH_______________________
VEHICLE MAKE______________ MODEL________________ YEAR_______ LICENSE #______________
ORGANIZATION NAME, ADDRESS, TELEPHONE # ___________________________________________
__________________________________________________________________________________________
BRIEF DESCRIPTION OF GOODS, WARES, MERCHANDISE OR SERVICES: ______________________
__________________________________________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF ANY CRIME?___________ IF YES, INDICATE CHARGE(S), PLACE,
DATE & PENALTY:
________________________________________________________________
_________________________________________________________________________________________
CORPORATE OFFICE POINT OF CONTACT (Name and Phone Number) ___________________________
_________________________________________________________________________________________
I, the undersigned, after being first duly cautioned and sworn, depose and say, that the above information is true and
complete to the best of my knowledge.
_______________________________________________ __________________________________________
Signature of Applicant Date
Approval to Process:_________________________________
