OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 email: licensing@tohmail.org
PEDDLING & SOLICITING
RENEWALFIRST TIME
1. Name:
1A. Social Security #
2. Local Address:
Email address:
3. Legal Address:
5. DOB: 5A. Age:
7. Race:
12. Are you a citizen ?
15. What commodities or services do you intend to sell ?
16. Are you a Veteran of the Armed Forces of the United States ?
17A. If YES, please give details:
19A. If YES
please give details:
17. Have you ever had a license or permit revoked ?
18. Do you have any charges pending against you ?:
If yes please give details
19. Were you ever convicted of any crime or offense except traffic infractions ?
21. Name of employer: Address of employer:
23. Remarks:
24. N.Y.S. Sales tax auth #:
13.
Native or
naturalized
:
8. Height:
9. Weight: 10. Eye Color:
Yrs.
6. Place of birth:
10A. Hair Color: 11. Complexion:
4. How long have you
resided at above address ?
3A. Phone #:
20
SUBMIT TWO PHOTOS
TAKEN WITHIN THE
PAST THIRTY DAYS
EACH 1 x 1
SHOWING ONLY NECK
SHOULDERS AND
UNCOVERED HEAD
SUBMIT TWO PHOTOS
TAKEN WITHIN THE
PAST THIRTY DAYS
EACH 1 x 1
SHOWING ONLY NECK
SHOULDERS AND
UNCOVERED HEAD
1/2’’ 1/2’’
Office Use Only
LICENSE #
ISSUED
Assigned
Badge #
IF VETERANS PERMIT IS ISSUED,
GIVE NUMBER OF
COUNTY LICENSE BELOW
YES NO
YES NO
YES NO
YES NO
YES NO
Where Penalty assessed
14. If Naturalized When
& Where
I solemnly swear to the truth of the above statements
Sworn to before me this
Day of 20
NOTARY PUBLIC
Signature of Applicant
Rev. 12-14 - W
click to sign
signature
click to edit
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