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Solicitor Permit ApplicationPLAINFIELD POLICE DEPARTMENT 14300 S. COIL PLUS DR. PLAINFIELD, IL 60544 (815) 436-6544 – Fax: (815) 436-1486 SOLICITOR APPLICATION DEPARTMENT STAMP RECEIVED BY:_ CITY OR COUNTY AND STATE START DATE END DATE ALARM COMPANIES ARE REQUIRED TO BE LICENSED BY THE STATE OF ILLINOIS. PLEASE PROVIDE THE FOLLOWING INFORMATION: SECURITY ALARM SALES: Specify if door-to-door solicitation includes a point-of-sale application process. YES NO ILLINOIS DEPT. PROFESSIONAL REGULATION LICENSE NUMBER:Expires: * If yes, we require you to provide your customer with an information packet regarding the Plainfield alarm ordinance and their responsibilities if they choose to have an alarm installed in their residence or business. I hereby certify that the foregoing information is true and correct to the best of my knowledge, and as an applicant, consent to independent verification of the information provided and agree to abide by the terms and regulations prescribed in the Village of Plainfield Solicitors Ordinance and by the terms of any license issued there under. SIGNATURE OF APPLICANT DATE OF APPLICATION HAIR COLOR LIST ALL PRODUCTS YOU WILL BE SELLING LIST ANY COMMUNITIES WHERE YOU HAVE SOLICITED IN THE LAST SIX MONTHS CITY OR COUNTY AND STATE START DATE END DATE CITY OR COUNTY AND STATE START DATE END DATE CITY OR COUNTY AND STATE START DATE END DATE APPLICANT INFORMATION NAME OF APPLICANT DATE OF APPLICATION ADDRESS CITY STATE ZIP CODE DATES FOR WHICH PERMIT IS DESIRED:THROUGH (60 Days Maximum) BUSINESS INFORMATION BUSINESS NAME TELEPHONE #NAME OF IMMEDIATE SUPERVISOR OR BUSINESS MANAGER ADDRESS CITY STATE ZIP CODE TELEPHONE #DRIVER’S LICENSE NUMBER DRIVER’S LICENSE STATE DATE OF BIRTH SEX M F RACE HEIGHT WEIGHT STATE: STATE: STATE: STATE: STATE: STATE: STATE: STATE: STATE: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: USE ADDITIONAL SHEETS IF NEEDED. DATE OF BIRTH: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: ADDRESS:STATE: ZIP: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: DATE OF BIRTH: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: NAME: (LAST – FIRST – MIDDLE) PHONE NUMBER: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: DATE OF BIRTH: ADDRESS:STATE: ZIP: DRIVERS LICENSE #: EXPIRES: IF MINOR, PROVIDE EMPLOYMENT CERTIFICATE # OR DEPT OF LABOR PERMIT #: PROVIDE THE FOLLOWING INFORMATION FOR EACH PERSON SOLICITING DATE OF BIRTH: ADDRESS:STATE: ZIP: PHONE NUMBER:NAME: (LAST – FIRST – MIDDLE)