Form: secondhand-jewelry-article-dealer-license-application

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Secondhand Jewelry & Article Dealer License Application

Fee: $57.50

License Term: January 1st thru December 31st

Name of Licensed Establishment:

Business Phone Number

Address of Licensed Premises

Street Address

Address of Licensed Premises

City

State/Province

Zip/Postal

Business Owner Name (Corporation / LLC / Partnership):

Business Owner's Phone Number

Business Owner Address

Street Address

Business Owner Address

City

State/Province

Zip/Postal

Applicant Name:

Applicant Phone Number

Applicant Address

Street Address

Applicant Address

City

State/Province

Zip/Postal

Applicant Driver's License Number

Applicant Date of Birth

Upload Picture of Applicant's Driver's License

Maximum file size: 52.43MB

List Names, Addresses, and Dates of Birth of all other Officers / Directors / Partners:

Have you or any other person listed on this application been convicted of a felony within the last ten (10) years?

Yes

If Yes, provide year of arrest, nature of the offense, and conviction information:

Have you or any other person listed on this application been convicted of a misdemeanor within the last five (5) years?

Yes

If Yes, provide year of arrest, nature of the offense, and conviction information:

Have you or any other person listed on this application been convicted of a statutory violation punishable by forfeiture?

Yes

If Yes, provide year of arrest, nature of the offense, and conviction information:

Have you or any other person listed on this application been convicted of a county or municipal ordinance violation?

Yes

If Yes, provide year of arrest, nature of the offense, and conviction information:

Under the provisions of the Village of Fox Crossing Municipal Code, the applicant hereby applies for a License for said business to be conducted on the aforementioned described premises in Fox Crossing.

Applicant understands that this license may be denied or revoked for fraud, misrepresentation, or false statement contained in the application or for any violation of WI Stat. §134.17, §943.34, §948.62, or §948.63.

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Date

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Secondhand Jewelry & Article Dealer License Application

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