Second hand Building Material

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

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Phone Number

Area Code Phone Number
Birth Date *

Month Day Year
Sex *
Race *
Drivers License #
Employment Information
Business Name
Business License #
Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Business Phone

Area Code Phone 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:

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