Peddler's License
May 05, 2022
submission
#15
Peddler's License Application
Applicant Information
| First Name | Gale "Jack" |
| Last Name | Jackson Jr |
| Home Address (No PO Boxes) | --- |
| Mailing Address | --- |
| Phone Number | --- |
| Date of Birth | --- |
| Weight | --- |
| Height | --- |
| Sex | --- |
| Hair Color | --- |
| Eye Color | --- |
| Driver's License # | --- |
| DL State Issued | --- |
| DL Expiration Date | --- |
| Social Security # | --- |
| Please include a recent photograph approximately two inches by two inches (2"x2") showing the head and shoulders of the applicant in a clear and distinguishing manner | --- |
| Have you ever been convicted of any crime, misdemeanor or violation of any municipal ordinance other than traffic violations? | --- |
Employment History
| Business Name, Address, Phone Number and Length of Employment: | --- |
Business Name & Location
| Business/Company Name | total home inspection services |
| Business Address | 9300 E Manzanita Cir, Prescott Valley AZ 86314-7215 |
| Business Mailing Address | 9300 E Manzanita Cir, Prescott Valley AZ 86314-7215 |
| Business Phone Number | +19287789101 |
| Please provide a brief description of the nature of the business and the goods to be sold: | --- |
| Please provide the source of supply of the goods or property proposed to be sold, or orders taken for the sale thereof; the location of the goods or products at the time this application is filed; and the proposed method of delivery: | --- |
| Vehicle Information; Which car will you be driving? | --- |
Vehicle information
| Make | --- |
| Model | --- |
| Year | --- |
| Color | --- |
| License Plate # | --- |
| State | --- |
Arizona Department of Revenue - Transaction Privilege Tax Number
| Please provide your Transaction Privilege Tax (TPT) Number (If none, write down service only) | --- |
Eligibility Form
Eligibility Form
| Choose one option: | Driver license issued by a state that verifies lawful presence in the United States (AK, AL, AZ, AR, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MS, MO, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT VA, VT, WI, WV and WY) |
| Attach a copy of said document |
|
Applicant Affidavit
| By submitting this application, I hereby certify that the statements made herein have been examined by me and are truthful to the best of my knowledge and understanding. | Agree |