FEE: $___25.00___

DATE:__________________

To the Clerk of the Town of Oconomowoc, WI.

(NOTE: Be sure to type or print legibly when completing this form!)

PERSONAL INFORMATION:

NAME: __________________________________________________________________________________

(First) (Middle) (Last)

PERMANENT ADDRESS: __________________________________________________________________

(Street) (P.O. Box Number)

___________________________________________________________________

(City) (State) (Zip)

TEMPORARY ADDRESS: __________________________________________________________________

(Street) (P.O. Box Number)

__________________________________________________________________

(City) (State) (Zip)

TELEPHONE NUMBER: (_____________) -_____________-_____________

HEIGHT_______’_______” WEIGHT _____________LBS HAIR COLOR_____________

EYE COLOR _____________ D.O.B. _______/________/_______

BUSINESS INFORMATION:

BUSINESS NAME: ________________________________________________________________________

BUSINESS ADDRESS: _____________________________________________________________________

(Street) (P.O. Box Number)

_____________________________________________________________________

(City) (State) (Zip)

TELEPHONE NUMBER: (_____________) -_____________-_____________

Describe the nature of the business to be conducted:________________________________________________

__________________________________________________________________________________________

Give a description of the merchandise or service(s) offered: _________________________________________

__________________________________________________________________________________________

Describe the method of delivery of merchandise, if applicable: ______________________________________

__________________________________________________________________________________________

List the make, model, and the license plate number of any vehicle to be used by the applicant in the conducting of this business: ____________________________________________________________________________

__________________________________________________________________________________________

List three cities/towns/villages where the applicant has conducted this business: _________________________

__________________________________________________________________________________________

Place where applicant can be contacted for at least seven days after leaving the Town of Oconomowoc: ______

__________________________________________________________________________________________

Have you been convicted of any license law or ordinance related to your transient business within the last five years: ____________________________________________________________________________________

__________________________________________________________________________________________

If you answered yes to the above question, state the nature of the offense and the place of the conviction: _____

__________________________________________________________________________________________

__________________________________________________________________________________________

PRESENT TO THE CLERK:

Proof of identity (i.e. a Driver’s License): _______________________________________________________

A State Certificate of Examination & Approval if business involves weights & measures: _________________

__________________________________________________________________________________________

A State Health Officer’s Certificate if business involves the handling of food or clothing: _________________

__________________________________________________________________________________________

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****(Your signature on this form acknowledges your understanding that a personal background check will be conducted, which includes but is not limited to, a criminal background check and a credit history check.)*****

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_______________________________________

(Signature of Applicant)

Police Approval

Yes________ No________

Subscribed and Sworn to before me on this

_____________ day of ______________, 20_______.

___________________________________

(Town of Oconomowoc Chief of Police)

____________________________________________

(Town of Oconomowoc Clerk-Treasurer)