Mobile Vendor Permit Application

Has the person making application, the local business manager or the owner(s) and operator(s) of the mobile vending unit had any criminal charges or convictions?*

YesNo
If yes, please state the date, charge, jurisdiction and description of such charges or convictions:
Has this mobile unit, the person making application, the local business manager or the owner(s) and operator(s) of the mobile vending unit been denied a permit or license by any state, local or federal jurisdiction?*

YesNo
If yes, please state the date, charge, jurisdiction and description of denial:
Name, address and phone number of entity that denied such application:

E-Signature of Responsible Party*

First NameLast Name
Today's Date*

MonthDayYear
Date
*By signing your name electronically on this form, you are agreeing that your
electronic signature is the legal equivalent of your manual signature.
Admin Use Only
Should be Empty: