NATURE OF BUSINESS THAT PERMIT COVERS

Honesdale Borough 958 Main Street, Honesdale PA 18431 Telephone: 570-253-0731 Permit Issued Under Chapter 152 - Peddling & Soliciting
PERMIT#
PERMIT FEE
PAID
DATE PERMIT ISSUED

MonthDayYear
Date
DATE PERMIT EFFECTIVE

MonthDayYear
Date
DATE PERMIT EXPIRES

MonthDayYear
Date
Nature of business that permit covers
NAME
HOME PHONE
Format: (000) 000-0000.
BUSINESS PHONE
Format: (000) 000-0000.
PRESENT ADDRESS
HOW LONG AT ADDRESS
AGE
SEX
HAIR COLOR
EYES
HEIGHT
WEIGHT
EMPLOYER
ADDRESS
POSITION HELD
IF VEHICLE IS USED:
STATE REGISTRATION VIN
LICENSE PLATESTATE
MAKE MODEL
OPERATORS LICENSE
WHERE WILL VEHICLE BE PARKED IN BOROUGH
HAVE YOU EVER BEEN CONVICTED OF A CRIME
IF YES EXPLAIN
TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS BELIEVED TO BE TRUE AND CORRECT.
SIGNATURE
PERMIT ISSUED BY
Date

MonthDayYear
Date
Supplemental Information Attached: 1. Copy of Photo ID 2. Copy of Vehicle Registration
Should be Empty: