Second hand Building Material

Second Hand Building Material "Junk Dealer" Permit Application
Permit #
Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Birth Date*

MonthDayYear
Sex*
Race*
Drivers License #
Employment Information
Business Name
Business License #
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Phone

Area CodePhone Number
Vehicles Used to Collect Materials
Year/Make/Model/Color*
Plate #*
Year/Make/Model/Color
Plate #
Year/Make/Model/Color
Plate #
FOR POLICE USE ONLY
Authorized Signature
Date
Approved/Denied
Should be Empty: