DATE:__________________ No.______________

COMPANY NAME:______________________________________________________

COMPANY ADDRESS:___________________________________________________

DBA:__________________________________________________________________

NAME AND PERMANENT ADDRESS OF ALL PERSONNEL WORKING UNDER THIS PERMIT:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

SOLICITOR

PEDDLER

CHARITABLE SOLICITOR

FEE:_________________

TYPE OF OPERATION:________________________________________________

DATE OF OPERATION:_________________TERMINATION:________________

APPLICANT NAME:__________________________________________________

APPLICANT ADDRESS:_______________________________________________

TELEPHONE:________________________________________________________

DRIVERS LICENSE:______________________________________Copy Attached

VEHICLE DESCRIPTION:_____________________________________________

Police Chief: Approval Disapproval

Reason for Disapproval:________________________________________________

(Seal)

__________________________ ___________________________

Chief of Police City Clerk

302 N. Redbud Trail 49107 Phone #269-695-3844 Fax# 269-695-4330