» Emerald Ash Borer (EAB) Beetle Notice

Name*

First Last

Phone Number*

This number will be called when permit is ready for pick-up

Height*

Weight*

Date of Birth*

Eye Color*

Hair Color*

Glasses*

Mustache*

Driver's License Number*

State Issued*

Date of Expiration*

Make & Year of Vehicle Driven*

Vehicle Plate Number*

State Issued*

Current Address*

Street Address City State ZIP Code

Have you had another address in the past year?*

Yes
No

Previous Address During Past Year*

Street Address City State ZIP Code

Are you required to register as a sex offender?*

Yes
No

Please provide details regarding your requirement to register as a sex offender.*

Have you been convicted of a felony or a misdemeanor involving dishonesty or false statements in the last five (5) years?*

Yes
No

Please provide details regarding your conviction.*

Permit Period Requested*

Thirty Day (30) Days - $50.00
One (1) Year - $200.00

Employment Information

All employment information for past year.

Date From	Date To	Type of Work	Employer’s Name, Address and Telephone No.

List of all certificates or registration or licenses obtained in the last year

Have you had any certificate of registration or license revoked in the last year?*

Yes
No

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THE VILLAGE OF MINOOKA AND THE MINOOKA POLICE DEPARTMENT AUTHORIZATION AND REQUEST FOR INFORMATION

I hereby authorize and empower the Village of Minooka and the Minooka Police Department, the Chief of Police, any consumer reporting agency, or other outside service company engaged by said officials, to obtain, prepare, use and furnish information concerning my current and former employment, current and former business practices, credit, general reputation, and personal characteristics. I respectfully request that you furnish to the Minooka Police Department, the Chief of Police any and all information that you have concerning me, my background, my business background and reputation. This information is to be used to determine the eligibility for the issuance of a permit to sell products in the Village of Minooka. I hereby release you and/or your employer from any liability and/or damage of whatsoever nature, on account of furnishing the information requested above.

Signature*

Witness*

If application is not signed in the presence of a Village of Minooka employee then you are required to have the form notarized. If you sign this form at Village Hall in the presence of an employee then no notarization is required for that employee will serve as your witness.

FOR OFFICIAL USE ONLY Solicitors permit ___________________ Peddlers & Itinerant Merchants __________________________
Date/s permit valid _____________________________________________________________________
Amount of cash deposited ______________________ OR
Type of Surety Bond ___________________ Issued by ________________________ In the Amount of _______________

Ric Offerman, Village President

Emerald Ash Borer (EAB) Beetle Notice

Employment Information

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