Application #
Fingerprint Tracking
Number #
ORI # FL752135Z
Ken Burke, CPA
Clerk of the Circuit Court and Comptroller
Pinellas County, FL
Home Solicitation Sales Permit - Application
PERSONAL INFORMATION
(First ) (Full Middle) (Last)
Name:
Phone # : Alternate Phone #:
Other names known by (Aliases/Maiden/Nicknames):
Local Residential Address:
Permanent Residential Address:
(if different than above)
How long have you resided in Pinellas County? In Florida?
Driver’s License #: Issuing State:
Date of Birth: Place of Birth:
Height: Weight: Hair: Eyes: Sex: Race:
Have you ever pled guilty, nolo contendere or been convicted of a crime? YES NO
If yes, provide nature of all charges, arresting police agency, date of arrest and final disposition (attach separate
sheets, if necessary):
EMPLOYER INFORMATION
Company Name: Type of Business: Phone:
Street Address: City State Zip
Applicant’s Signature: Date:
The foregoing instrument was acknowledged before me this day of , 20_ _, by
_, who has produced a Florida driver’s license or
as identification (or who is personally known to me) and who did take an oath that the
information provided in the application is true and complete, and the he/she has complied with all criteria and procedures
required by Chapter 86-144, General Laws of Florida, to the best of his/her knowledge.
Notary Public
Rev. 06/20
