Application for Licensing under C.G.S. Chapters 409/414
Date of Application:
Name of Business:
Street Address:
Town or City/State:
Zip/Postal Code:
Business Phone: Home Phone:
Cell Phone:Applicant's Current Occupation:
Type of Application:
Initial License fee $50
Renewal $25
Initial License fee $250
Renewal $100
Initial License fee $10
Precious Metal or Stones Dealer
Renewal $10
BRANFORD POLICE DEPARTMENT
33 Laurel Street
Branford, Connecticut 06405
Phone : 203-481-4241
Last Name of Applicant:
First Name of Applicant:
Middle Name of Applicant:
Applicant's Date of Birth:
Street Address:
Town or City/State:
Zip/Postal Code:
Sex:
Race:
Type of Business:
Place of Birth
BUSINESS ADDRESS APPLICANT'S RESIDENTIAL ADDRESS
Age:
Date of Fingerprint:
Pawnbroker
Secondhand Dealer
Renewal fee waived with
Secondhand License
Fax : 203-315-0254
List all of the residential addresses used by the applicant over the past five years:
Street Address City/Town & State, Zip Code Dates resided from/to :
List all locations used or intended to be used for the purchase, receipt, storage or sale of property :
Physical address of property (include unit #) City/Town & State, Zip Code Use/intended use:
Check here if an additional sheet is attached for locations
used by business for purchase, receipt, storage or sale of property
Check here if an additional sheet is attached for
applicant's residential addresses
Page 1
Name of Applicant:
1. Current or most recent
Name of Employer:
Name of last supervisor:
Dates of employment:
Complete Address:
Phone #:
Last job title:
From: To:
2.
Name of Employer:
Name of last supervisor:
Dates of employment:
Complete Address:
Phone #:
Last job title:
From: To:
3.
Name of Employer:
Name of last supervisor:
Dates of employment:
Complete Address:
Phone #:
Last job title:
From: To:
Check here if an additional sheet is attached for applicant's employment history
Name of Business:
Name of last supervisor:
Dates of employment:
Complete Address:
Phone #:
Last job title:
From: To:
Check here if an additional sheet is attached for applicant's previous experience
Date of Application:
Page 2
EMPLOYMENT HISTORY (past five years)
PREVIOUS EXPERIENCE Has applicant had previous experience in the type of business for which a license is being sought under this application:
Crime Arresting Agency Date of Conviction Court Where Convicted
Check if you have never been convicted of a crime
Check here if an additional sheet is attached for criminal history
Name of Applicant: Date of Application:
Select One
Individual's Relationship to Business
Name Address Phone Number
Select One
Select One
Select One
Check here if an additional sheet is attached for EMPLOYEES, PRINCIPALS IN BUSINESS, OFFICERS, SHAREHOLDERS, FINANCIAL BACKER or CREDITORS
I hereby certify that the information provided is true and accurate. I understand that if I have falsified any information in this application
or on the attached _____ pages, I will not be entitled to the license sought or this license may be revoked or suspended, after notice
and hearing, if information is found to be false after the license has been issued. I fully understand that if I intentionally make a
statement that is untrue and which is intended to mislead a public servant in the performance of his or her official function, I will be in
violation of Section 53a-157b of the Connecticut General Statutes for False Statement and may be subject to arrest.
Date: ______________________________ Signature of Applicant: ________________________________________________________
(Must be signed in the presence of a Notary Public)
Subscribed and sworn to before me this ____________ day of _______________, 20_______, in accordance with the Connecticut
General Statutes.
_____________________________________________ __________________________________________
Signature of Notary Public Print Name of Notary Public
My Commission expires: ________________________
Page 3
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Check here if an additional sheet is attached for Internet Web Sites and Accounts
CRIMINAL HISTORY - List all crimes for which you have been convicted.
EMPLOYEES, PRINCIPALS IN BUSINESS, OFFICERS, SHAREHOLDERS, FINANCIAL BACKER or CREDITORS
List all persons required to be reported under Chapter 409 of the C.G.S.
INTERNET WEB SITES, ACCOUNTS OR EMAIL ADDRESSES List all sites, accounts and addresses required under C.G.S. Chapter 409.
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