RICHMONDPOLICEDEPARTMENT
PERMITAPPLICATION
ChecktheTypeofPermitApplicationRequest
Initial Renewal
AmusementPark Gold/SilverMerchant SecondhandDealer
BilliardParlor JunkDealer SkatingRink
BowlingAlley MerryGoRound Solicitor
Carnival Palmistry TaxiCabOperator’sPermit
Circus/WildWestShow Pawnshop Theater/MotionPicture
EmploymentService
Pistols&Ammunition&Sales
(LicenseddealerscompleteSections9&10only)
Miscellaneous

NOTE
Pleaseanswerquestionscompletelyandaccurately.Allanswersmustbeprintedneatlyortyped.
Ifthereisinsufficientspaceforyouranswer,listthesectionnumberandansweronaseparatepieceofpaper.
Activityforwhichthepermitisbeingrequested:

NameofPartnershiporFirm(forbusinesspermitrenewal):

Address
   
Street City State ZipCode
ContactName(forbusinesspermitrenewal):

ContactAddress:
   
Street City State ZipCode
ContactTelephoneNumber:
  
Home Wor
k
Ce
ll
Thelengthoftimeittakestoconductaninvestigationdependsontheaccuracyandcompletenessofyourapplication.
Ifyouhaveanyfurtherquestions,pleasecontacttheRichmondPoliceDepartmentPermits&Inspections
Sgt.CorettaMonts(804)6466774
Off.JerryBaskette(804)6464950(PawnShops/Gold&
Silver) Off.AliceSnell(804)6465359(TaxiCabs)
DateSubmittedtoRichmondPoliceDepartment: 
2
SECTION1PERSONALHISTORY
LegalNameatBirth
AllOtherNamesyouhaveused(nickname,maidenname,etc.)
SocialSecurityNumber
Race Sex Height
ft in
Weight
lbs
EyeColor HairColor
ListanyScars,MarksorTattoos
DateofBirth PlaceofBirth
City/County State Country
AreyouaU.S.Citizen?
Yes No
IfNaturalized,DateofNaturalization GreenCard#(Ifapplicable)
Haveyoueverbeenarrestedforanyreason? No Yes
Ifyes,Explain(includingDUI):
3
SECTION2DRIVINGHISTORY
PleaseprovidetheinformationonanyVehicleOperator’sLicense/Permityouhaveheld
TypeofLicense StateofIssuance LicenseNumber DateIssued DateExpired
ListALLTrafficViolationsorCitations(excludingParkingTickets)thatyouhavereceivedinthepast10YEARS
1
Date Charge
LocationofCharge DispositionofCharge
2
Date Charge
LocationofCharge DispositionofCharge
3
Date Charge
LocationofCharge DispositionofCharge
4
Date Charge
LocationofCharge DispositionofCharge
5
Date Charge
LocationofCharge DispositionofCharge
4
SECTION3EMPLOYMENTHISTORY
StartwithyourPRESENTEMPLOYERandworkbackward.
Includeany/allperiodsofUnemploymentandany/allperiodsofSelfEmployment
EmployedFrom
‐
EmployedTo NameofEmployer
Employer’sCompleteAddress Employer’sTelephoneNumber
PositionHeld ReasonforLeaving
EmployedFrom
‐
EmployedTo NameofEmployer
Employer’sCompleteAddress Employer’sTelephoneNumber
PositionHeld ReasonforLeaving
EmployedFrom
‐
EmployedTo NameofEmployer
Employer’sCompleteAddress Employer’sTelephoneNumber
PositionHeld ReasonforLeaving
EmployedFrom
‐
EmployedTo NameofEmployer
Employer’sCompleteAddress Employer’sTelephoneNumber
PositionHeld ReasonforLeaving
EmployedFrom
‐
EmployedTo NameofEmployer
Employer’sCompleteAddress Employer’sTelephoneNumber
PositionHeld ReasonforLeaving
5
SECTION4ADDITIONALINFORMATION
Haveyoueverbeendeniedapermitorlicensesimilartotheoneyouareapplyingfornow? No Yes
Ifyes,Explain:
Haveyoueverbeendeniedemploymentbyalaw enforcementagency? No Yes
Ifyes,Explain:
DoyouhaveanyfriendsorrelativeswhoareemployedbytheRichmondPoliceDepartment? No Yes
Ifyes,listbelow:
6
SECTION5RESIDENTIALHISTORY
BeginningwithyourCURRENTADDRESS,listallpreviousplacesofresidence(includedates,address,city,state)
From
(Month/Year)
Until
(Month/Year)
Address(Street,City,State)
7
SECTION6FAMILYANDHOUSEHOLD
Name Address(Street,City,State) DOB
Father
Mother
Spouse
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
Brother/Sister/Child
8
SECTION7PERSONALREFERENCES
ListFIVE(5)PersonalReferencesDONOTincluderelativeoremployees
Name DateofBirth
Address
Street City State Zip
Telephone
Name DateofBirth
Address
Street City State Zip
Telephone
Name DateofBirth
Address
Street City State Zip
Telephone
Name DateofBirth
Address
Street City State Zip
Telephone
Name DateofBirth
Address
Street City State Zip
Telephone
9
SECTION8APPLICANTSFORTAXICABOPERATOR’SPERMITONLY
Hasyouroperator’slicenseeverbeensuspendedorrevoked? No Yes(attachcopyofcurrentDMVrecord)
Ifyes,Explain:
Doyouhaveanyhearingoreyesightproblems? No Yes
Ifyes,Explain:
Haveyoueverdrivenataxicabbefore? No Yes
Ifyes,listcompany(s)anddate(s):
CompanyName Date(s)
Listyourcurrenttaxicabpermitnumber:
Whatisthetradename,addressandphonenumberofthecompanyforwhichyoucurrentlydrive?
Name Telephone
Street City State ZipCode
NameoftheCompanyOfficialwhohiredyou:
SECTION9BUSINESSINFORMATION(FORBUSINESSPERMITRENEWALS)
BusinessName Telephone
BusinessAddress(Physical)
Street City State ZipCode
BusinessAddress(Mailing,ifdifferentfromabove)
Street City State ZipCode
Isthisbusinessa Partnership Corporation Other(specify)
Listthename,dateofbirth,socialsecuritynumberandpositionheldinthebusinessforeachindividualowner,partner,
andallotherresponsiblepersons,includingyourself
Name PositionHeld SocialSecurityNumberDateofBirth
TypeofBusiness:
StoreFront
Office
Rod&GunClub
Hotel/Motel
Multifamilydwelling
Singlefamilydwelling
10
SECTION10PISTOL&AMMUNITIONSALESLICENSEDDEALER
1. Istheapplicantalicensedfirearmdealerpursuantto18USC§921etseq.? Yes No
a. Ifyes,listFed eralFirearmsLicenseNumber:
b. Individual(s)whosename(s)appearonFederalFirearmsLicense:
1.
2.
3.
4.
5.
2. IstheapplicantafirearmsdealerregisteredwiththeVirginiaStatePoliceDepartment Yes No
a. Ifyes,listVSPIdentificationNumber:
b. AttachacopyofcompletedFirearmsDealerRegistrationformdisplayingVSPIdentification Number(withall
attachments)
11
DECLARATIONPAGE
IcertifythatIhaveexaminedthisapplicationandthedocumentssubmittedinsupport
thereof, and to the best of my knowledge and belief, they are true, correct and
complete.
Ihaveneitherwithheldnormisrepresentedanyfactscontainedherein.
By my signature below, I authorize the Richmond Police Department to co nduct an
investigationintomybackgroundtodetermine myqualificationsforthe permit and/or
licensethatIamseeking.
I also understand that any falsification or misstatement of material facts may be
groundsfordenialofthisapplication.
Applicant’sSignature Date
COMMONWEALTHOFVIRGINIA
CITY/COUNTYOF_______________________________,TOWIT:
Theforegoingdocumentwasacknowledgedbeforemethis________dayof______________,
_______________by___________________________________________________________.
Mycommissionexpires: ______________________________
________________________________________________________
NotaryPublic
**********ALLAPPLICATIONSMUSTBENOTARIZED**********
12
RICHMONDPOLICEDEPARTMENT
AUTHORIZATIONFORRELEASEOFINFORMATION
APPLICANT’SNAME:_________________________________________________
I respectfully request and authorize you to furnish the City of Richmond Police
Department, any and all information in your possession concerning my
employment record, educational record, military record, re putation, character,
financial and credit status.Please include any and all polyg
raph results,
application information and other information of a confidential nature, and
Photostats/Copiesofsame.
This information is to be used to assist the Richmond Police Department in
determiningmyqualifications/fitnessforthepermitIamseeking.Areproduction
of this release form will be as an original hereof and shall expire 12 (twelve)
mont
hsfromthedateofitsacknowledg
ement.
I hereby release you, your organization and others from any and all liability or
damage which may result from furnishing the information requested.I further
understand that the sources of information, as well as the information itself,
cannotbereveale
dtome.
ApplicantSignature Date
Address
Street City State ZipCode
SocialSecurityNumber DateofBirth
WitnessSignature Date
MUSTBESIGNEDBYNOTARYORSOMEONEWHOWITNESSESYOURSIGNATURE
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