City of Des Moines
21630 11th Avenue South
Des Moines, WA 98198
SOLICITOR’S APPLICATION
DMMC 5.08
Fee - $100.00 1-5 salesman, additional $20.00 each for 6 or more.
Name of Applicant ______________________________ Employer: _______________________
(REQUIRES first, middle initial & last)
Present Address: ______________________________ Address: ________________________
______________________________ ________________________________
Telephone Number: _______________________(home) __________________________(Work)
Length of time at present address: _______ Address of residence during past 3 years if different
from above:
________________________________________________________________________________
________________________________________________________________________________
Height: __________ Weight: __________ Eye Color: __________ Hair Color: ___________
Date of Birth: _______________ Social Security #: _________________________________
Drivers License #: ____________________________ State Issued From: ____________________
Vehicle Type & Year: ____________________________ Auto License #: ____________________
Name & address of employer during past three years:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Name of person, firm, corporation, or association applicant represents:
Name: _____________________________ Address: _____________________________________
Time associated with above firm: _______________
Approximate date of the last application for a solicitor permit, if any: ___________
Names of the three most recent cities/communities where you have solicited door to door:
Detailed description of subject matter/article for which solicitation is to be made:
________________________________________________________________________________
Period of time for which certificate is to be applied (one year maximum): ______________________
Have you ever been convicted of a felony under the laws of this State or any other state or federal
law of the United States? ___________________________________________________________
If this permit is being requested for a community based non-profit organization, please list below the
names (first, middle initial & last names), date of birth, and addresses of all individuals who will be
soliciting. (Attach an additional sheet if necessary.)
Name: ________________________________________________ DOB: ____________________
Address: ________________________________________________________________________
Name: ________________________________________________ DOB: ____________________
Address: ________________________________________________________________________
Name: ________________________________________________ DOB: ____________________
Address: ________________________________________________________________________
OATH:
I hereby certify that there are no misrepresentations or falsifications in these statements and
answers to questions. I am aware that any misstatements of material facts may cause
rejection of my application.
Date: __________________ ________________________________________________
APPLICANT’S SIGNATURE
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OFFICE USE ONLY
APPROVED:
Chief of Police City Clerk
Card Number Issued: ____________________
Expiration Date: ________________________
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