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Fee: $40.00/mo.
Receipt No.
1. Name:
Permanent Address:
Telephone Number:
Temporary Address (if
Date of Birth:
Hair Color:
Eye Color:
3. Name of person, firm, association or corporation that the Direct Seller represents or is employed by, or
whose merchandise is being sold:
Telephone No:
4. Temporary address and telephone number from which business will be conducted, if any:
Telephone No:
5. Nature of business to be conducted and a brief description of the goods offered, and any services offered:
6. Proposed method of delivery of goods:
7. Make, model and license number of any vehicle to be used by applicant in the conduct of his/her business:
8. Last cities, villages, towns, not to exceed three, where applicant conducted similar business:
9. Place where applicant can be contacted for at least seven days after leaving the City:
10. Statement as to whether applicant has been convicted of any crime or ordinance violation related to
applicant's transient merchant business within the last five years, the nature of the offense, and the place of
Signature of Applicant:
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Applicants shall present to the Clerk for examination:
1. A driver's license or some other proof of identity as may be reasonably required.
2. A state certificate of examination and approval from the Sealer of Weights and Measures
where applicant's business requires use of weighing and measuring devices approved by
State authorities.
3. A state health officer's certificate where applicant's business involves the handling of
food or clothing and is required to be certified under state law; such certificate to state
that applicant is apparently free from any contagious or infectious disease, dated not more
than 90 days prior to the date the application for license is made.
At the time the registration is returned, a fee of $40.00 shall be paid to the Clerk to cover the
cost of processing said registration.
Upon receipt of each application, the Clerk may refer it immediately to the Chief of Police who
may make and complete an investigation of the statements made in such registration.
Any charitable organization not registered under Section 440.41, Wisconsin Statutes, or which
is exempt from that Statute's registration requirements, shall be required to register under this
Each applicant must sign the following statement:
I /we do hereby nominate and appoint the Clerk of the City of Portage as my/our agent to accept
service of process in any civil action brought against me/us arising out of any sale or service
performed by me/us, in connection with the direct sales activity of me/us, in the event that I/we
cannot be personally found or located for personal service of such process.
Signature of Applicant