EmailMe Form - Jermyn Borough Application for Solicitation Permit

Please note that payment has been disabled on this form.
You may notify the owner and continue to submit the form.

Name *
First Last
License Number *
Phone
### - ### - ####
State *
Date of Birth *
Place of Birth *
Age *
Height *
Gender
Male
Female
Weight *
Have You Ever Been Arrested or Convicted of a Felony, Misdemeanor, or a Crime of Any Kind? *
Yes
No
Hair Color *
Eye Color
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Employer/Business Name *
Employer Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Business Phone *
### - ### - ####
What Goods or Services Will You Be Soliciting? *
Length of Time Applicant Wishes to Solicit (Max 4 Months) *
Vehicle Year, Make, Model, Color
License Plate #
State
By Checking This Box, I Agree that on behalf of the employer and in consideration of the issuance of such licenses or permit, employer agrees to become liable and responsible for any and all acts of the solicitor while within the Borough, in violation of a law or otherwise.
I Agree
Each Application May Include One Solicitor and One Vehicle *
Solicitor ($100)
Vehicle ($25)