Name of Employer (if self-employed list “self”):
________________________________________________
Address of
Employer:________________________________________________
Number/ Street________________________________________________
Contact #________________________________________
City/ State / Zip ________________________________
Vehicle Registration #:______________________
Vehicle Color: __________________ Vehicle Year: __________
Vehicle Make: _______________
Vehicle Model: ______________
Are you paid or compensated in any way for your soliciting activity? □ Yes□
No I declare that the above facts are true and complete to the best of my
knowledge and belief and I understand that any false answer(s) will be just
cause for denial or revocation of my License to Solicit. Signed under the
penalties of perjury this _________ day of _________________,
___________ . (day)(month) (year)
Signature of Applicant: ___________________________
In order to submit this application, you must make an appointment. Before
requesting an appointment, please read and understand the entire text of the
solicitation by-law (available at www.town.rockland.ma.us). To arrange an
appointment, call Ofc Jeffrey Direnzo 781-871-3890 Ext 124.
DEPARTMENT USE ONLY
Received ___________ Approved _________ Denied _______ Investigator __________
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