SOLICITOR APPLICATION
FOR CERTIFICATE OF REGISTRATION
Community & Economic Development Dept • 1979 W 1900 S • Syracuse, UT 84075
Phone: (801) 825-1477 • Email: hdavies@syracuseut.com
Date of Application: ____________________ Start Date: ____________________
BUSINESS INFORMATION:
Business Name: ____________________________________________ DBA Name:________________________________________________
Business Address: __________________________________ City: _________________ County
: ______________ State: ____ Zip: _________
Business Mailing Address: ______________________________________ City: ____________________________ State: ____ Zip:__________
Contact Person Name: ______________________________ Contact Phone#: ____________________ Email: __________________________
Business State Sales Tax #: _________________________ Dept. of Commerce Business Name Registration #: _________________________
ITEMS REQUIRED TO BE SUBMITTED WITH APPLICATION:
Proof of Identification (one of the following):
Utah Criminal History Record performed by Utah BCI bci.utah.gov
(less than 180 days old or from previous State if lived in Utah less than 6 months)
a) Valid State-issued Driver License or Identification Card
Recent Photo of Applicant (Emailed to Business License Clerk)
Portrait/passport style jpg photo, see below for sample
b) Valid Passport issued by the United States
c) Valid U.S.A. Military Identification Card
Proof of State Sales Tax or Special events Sales Tax #
Describe
in Detail
the Goods and/or Services Offered: ________________________________________________________________________
____________________________________________________________________________________________________________________
Hours and Days of Solicitation: Mon Tues Wed Thurs Fri Sat S
un; _____ AM PM to _____ AM PM
Are there any licenses or permits required
to transact this business: Yes No If YES, Please provide a copy of license and/or permit.
QUALIFYING STATUS QUESTIONS:
Affirm or Deny Each Statement. Any affirmation response in this section renders the applicant disqualified from certification.
1. I have been criminally convicted for: a) Felony homicide: Yes No b) Sexual offense of any kind: Yes No
c) Physically/sexually abusing or exploiting an adult or minor: Yes No d) Sale/distribution of controlled substances: Yes No
2. I have criminal charges currently pending for: a) Felony homicide: Yes No b) Sexual offense of any kind: Yes No
c) Physically/sexually abusing or exploiting an adult or minor: Yes No d) Sale/distribution of controlled substances: Yes No
3. I have had a criminal felony conviction within the last ten (10) years: Yes No
4. I have been incarcerated in a federal or state prison within the past five (5) years: Yes No
5. I have been criminally convicted of a misdemeanor within the past five (5) years involving a crime of:
a) Violent or aggravated conduct involving persons or property: Yes No b) Moral turpitude: Yes No
6. I have, within the last five (5) years, had a final civil judgement or subject of an administrative order issued in any state for:
a)
Engaged in/admission of fraud or intentional misrepresentation: Yes No b) Engaged in willful or malicious activity: Yes No
7.
I am currently on parole or probation to any court, penal institution, or governmental entity, including being under house arrest or
subject to a tracking device: Yes No
8. I have an outstanding arrest warrant from any jurisdiction: Yes No
9. I am currently subject to a protective order based on physical or sexual abuse: Yes No
10. I have had two (2) or more convictions of, or any combination of the following: Trespass, trespassery voyeurism, any property crimes,
or any violation of Syracuse Municipal Code: Yes No
Applicant’s Full Legal Name (first, middle, last): ______________________________________________________________________________
Applicant’s Date of Birth: _______________ Driver License#: ___________________ State: _____ Other ID: ____________________________
All Former Names/Aliases Used by Applicant in Last 10 Years: __________________________________________________________________
Applicant’s Home Address: ________________________________________ City: _________________________ State: ____ Zip: __________
Applicant’s Phone #: ___________________________________
