Peddler's License Application
Applicant Information
| First Name |
Amanda
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| Last Name |
Cox
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| Home Address (No PO Boxes) |
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| Mailing Address |
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| Phone Number |
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| Date of Birth |
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| Weight |
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| Height |
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| Sex |
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| Hair Color |
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| Eye Color |
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| Driver's License # |
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| DL State Issued |
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| DL Expiration Date |
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| Social Security # |
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| 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 |
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| Have you ever been convicted of any crime, misdemeanor or violation of any municipal ordinance other than traffic violations? |
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Employment History
| Business Name, Address, Phone Number and Length of Employment: |
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Business Name & Location
| Business/Company Name |
Cox Medical Clinics
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| Business Address |
1579 W Gurley St Ste A, Prescott AZ 86305-2880
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| Business Mailing Address |
1579 W Gurley St Ste A-39, Prescott AZ 86305-2870
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| Business Phone Number |
+19284402080
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| Please provide a brief description of the nature of the business and the goods to be sold: |
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| 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: |
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| Vehicle Information; Which car will you be driving? |
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Vehicle information
| Make |
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| Model |
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| Year |
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| Color |
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| License Plate # |
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| State |
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Arizona Department of Revenue - Transaction Privilege Tax Number
| Please provide your Transaction Privilege Tax (TPT) Number (If none, write down service only) |
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Eligibility Form
Eligibility Form
| Choose one option: |
Arizona driver license issued after 1996 OR Arizona non-operating identification license
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| Attach a copy of said document |
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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
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