Page 1 of 2 (Individual revised 12/17/09)
CIT
Y OF
ELOY
PEDDLERS/SOLICITOR
S
(
SPECIAL EVENTS APPLICATION
)
NAME:
ADDRESS:
DESCRIBE NATURE OF BUSINESS:
GOODS TO BE SOLD:
EMPLOYER NAME:
ADDRESS:
HOW LONG DO YOU WISH LICENSE FOR?
DATES NEED:
CHARGES: 1DAY
2 DAY
3 DAYS
MORE DAYS
$10.00 $20.00 $30.00 $10.00 PER DAY
DESCRIPTION OF VEHICLE:
VEHICLE LICENSE NUMBER:
PHOTOGRAPH (attached)
FINGERPRINTS (attached)
COPY OF DRIVERS LICENSE (attached)
COPY HEALTH FOOD CERTIFICATE (attached)
Yes No
Yes No
Yes No
Yes No
PLEASE STATE ALL CONVICTIONS OF ANY CRIME, MISDEMEANOR (EXCEPT MINOR TRAFFIC
VIOLATIONS), AND VIOLATION OF MUNICIPAL CODE LAWS, THE NATURE OF THE OFFENSE AND
PUNISHMENT OR PENALTY.
Signature of Applicant Date
--------------------------------------------DO
NOT WRITE BELOW THIS LINE------------------------------------------
APPROVED:
DATE:
DENIED:
DATE:
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Page 2 of 2 (Individual revised 12/17/09)
CITY OF ELOY PEDDLERS/SOLICITORS LICENSE
INFORMATION
Name:
Home Address:
City/State/Zip:
Telephone: Fax: Email:
Social Security #: Date of Birth:
Driver’s License #: State of Issuance:
Height: Weight: Hair:
Eyes:
EMERGENCY CONTACT DURING NON-BUSINESS HOURS:
Name:
Telephone #: _
Address:
City/State/Zip:
City of Eloy
Finance Department
628 North Main Street
Eloy, Arizona, 85131
Licensing Eligibility Requirement Form (ARS § 41-1080)
Effective October 1, 2008, a new law went into effect preventing the City from issuing a license (either new or
renewed) to an individual unless the individual has provided the City of Eloy with one of the forms of
identification listed below. If your business is incorporated, provide a certificate of good standing.
To become or remain eligible for a license, complete this form and present one of the forms of identification as
Listed below to the City of Eloys Finance Department for processing. Please indicate which form is presented.
An Arizona driver license issued after 1996 or an Arizona non-operating identification
A driver license issued by a state that verifies lawful presence in the United States. (Licenses
From HI, IL, ME, MD, NM, TX, UT and WA are not acceptable.)
A birth certificate or delayed birth certificate issued in any state, territory or possession of the
United States.
A United States certificate of birth abroad.
A United States passport.
A foreign passport with a United States visa.
An I-94 form with a photograph.
An United States citizenship and immigration services employment authorization document or
Refugee travel document.
A United States certificate of naturalization.
A United States certificate of citizenship.
A tribal certificate of Indian blood.
A tribal or Bureau of Indian Affairs affidavit of birth.
Corporate certificate of good standing
By my signature below, I hereby certify, under penalty of perjury, that I am legally authorized to be present in
the United States.
Full Signature of Licensee Date
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signature
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