APPLICATION HOME SOLICITORS PERMIT BREVARD COUNTY, FLORIDA _________________________________________________________________________________________________________ Name (f irst , middle, last ) _________________________________________________________________________________________________________ Social Securit y Number _________________________________________________________________________________________________________ Permanent Residence Address _________________________________________________________________________________________________________ Business Telephone Number _________________________________________________________________________________________________________ Home Telephone Number _________________________________________________________________________________________________________ Local Residence A ddress _________________________________________________________________________________________________________ Dat e of Birt h _________________________________________________________________________________________________________ Place of Birt h (cit y and st at e) _________________________________________________________________________________________________________ Race _________________________________________________________________________________________________________ Sex _________________________________________________________________________________________________________ Marit al St at us _________________________________________________________________________________________________________ Employer' s Name _________________________________________________________________________________________________________ Employer' s A ddress Have you ev er been conv ict ed of , pleaded Guilt y or Nolo Cont endere to any Crime? Yes No If Y es, st at e t he nat ure of t he off ense; place of of f ense; punishment or penalty assessed t heref or: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ I hav e current required Count y or Municipal Oc cupat ional License. I underst and t hat t his Permit can or w ill be revoked if I am conv ict ed of , plea Guilt y or Nolo Contendere t o any crime in any jurisdict ion. I d o sol emn ly sw ear t h at a ll o f t h e abo ve is t r ue an d co rr ect . A pplicant ' s Signat ure STA TE OF FLORIDA COUNTY OF BREV A RD The f oregoing inst rucment w as acknow ledged bef ore me on t his _____ day of ____________________, 20 ____, by _______________________________________________________________, w ho is personally know n to me or w ho has produced _________________________________________ as ident if icat ion and w ho did did not t ake an oat h. Not ary Public Print or t ype name Law 963 New 04/2005 American LegalNet, Inc. www.USCourtForms.com