Fillable Applicant Information 5171 Northwest Parkway, Hilliard, OH 43026 (City of Hilliard)

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Applicant Information 5171 Northwest Parkway, Hilliard, OH 43026 (City of Hilliard)

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HPD-090 (Rev. 07-18) Pg. 1 of 2
Applicant Information
First Name:
Middle Name:
Last Name:
Email:
Cell:
Social Security #:
Date of Birth:
Height:
Weight:
Eye Color:
Home Address:
City:
Zip:
Temporary Address:
City:
Zip
List any community where you have conducted peddling or solicitation activities within the past 6 months:
List all criminal convictions other than minor traffic within the past five (5) years:
All Additional Places of Residence for Applicant in the Past 12 Months
Street Address:
City:
State:
Zip:
Street Address:
City:
State:
Zip:
Street Address:
City:
State:
Zip:
Street Address:
City:
State:
Zip:
Street Address:
City:
State:
Zip:
Company Information
Corporate/Business or dba Name:
Address:
City:
State:
Zip:
Business Phone:
Supervisor’s Name:
Supervisor’s Phone:
Length of Time Employed By Company:
Type of Business/ Description of Merchandise/Product for Sale/Services Furnished:
Vehicle Information
Color:
Year:
Make:
Model:
License Number:
State in Which Vehicle is Registered:
TRANSIENT VENDOR APPLICATION
Hilliard Division of Police
5171 Northwest Parkway, Hilliard, OH 43026
Phone: 614.876.2429 Email: hilliardpolice@hilliardohio.gov
CLEAR FORM
HPD-090 (Rev. 07-18) Pg. 2 of 2
All Additional Employment for Applicant in the Past 12 Months
Business Name:
Street Address:
City:
State:
Zip:
Business Name:
Street Address:
City:
State:
Zip:
Business Name:
Street Address:
City:
State:
Zip:
Required Documents & Fee
$50.00 Non-refundable Application Fee (No cash or credit cards accepted.)
______Check
(Payable to City of Hilliard) ______Money Order
Show valid driver’s license or government issued identification. If applicant is not a U.S. citizen, show valid
passport from country of origin and proof of legal entrance into the U.S. and authorization to work.
Provide, in its entirety, a copy of recent Ohio Bureau of Criminal Investigation (BCI) or Federal Bureau of
Investigation (FBI) background results. Any WebCheck location can submit your fingerprints to BCI/FBI;
however, as a courtesy, we have provided the information for two local companies. Request that the
WebCheck processor send the BCI/FBI results directly to you, NOT the City of Hilliard.
• Northwest Kiwanis Deputy Register, 4740 Cemetery Road, Hilliard, Ohio 43026. Ph: 614.529.1203
• Biometric Information Management, 6059 Frantz Rd, Ste 102, Dublin, Ohio 43017. Ph: 614.456.1296
Photo Taken On-site
Certification
I certify that all information provided on this application is correct. I certify that any criminal history I have has
been included with this application. I understand that any falsification will result in revocation of the permit.
I certify that, if granted a permit, I will not use the permit as an endorsement by the City, a city department or city
employee of my company or products or services peddled/solicited.
I certify that I have been given a copy of Chapter 745 of the City of Hilliard Codified Ordinances.
I certify that, if granted a permit, I will maintain compliance with Chapter 745 of the City of Hilliard Codified
Ordinances and all applicable county and state statutes, rules and regulations that affect transient vendors.
Applicant Signature: ______________________________________________________ Date: ________________________________
For Administrative Use Only
Approved?
Yes
No
Remarks:
ID Tag/License Printed Called/Left Voicemail for Pickup
Reviewed By:
Receipt #:
Permit #:
Permit Dates:
From:
To:
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Applicant Information 5171 Northwest Parkway, Hilliard, OH 43026 (City of Hilliard)

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Completed 3 August 2020

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