20___ STATE OF VERMONT APPLICATION FOR SOLICITOR’S PERMIT LICENSE YEAR: May 1st through April 30th of following year. Fee of $50.00 by CERTIFIED CHECK must accompany this application. Make check payable to and mail to: Vermont Department of Liquor Control, Drawer 20, Montpelier, Vermont 05620-4501 To the Liquor Control Board, Montpelier, Vermont, Application is hereby made for a permit to solicit orders for and promote the sale of malt and vinous beverages under and in accordance with Title 7 of the Vermont Statutes annotated, as amended, and I certify that all statements, information and answers to questions herein contained are true, and in consideration of such permit being granted, do promise and agree to comply with all local and state laws; to comply with all regulations made and promulgated by the Liquor Control Board; and, upon hearing, the Liquor Control Board may in its discretion suspend or revoke said permit whenever it determines that the law or any regulations of the Liquor Control Board have been violated, or that any statements, information or answers herein contained are false. NAME of applicant: ADDRESS of applicant: Has applicant previously held a solicitor’s permit? If so, what year? Does applicant hold any elective or appointive state, county, city, village, or town office in the State of Vermont (VSA T.7 Ch. 9, § 223)?Yes No If so,give name of office Has the applicant ever been convicted or pled guilty to any criminal or motor vehicle offense in any court of law? No If yes, please explain on the back of this application the offense, court and date. Yes Have you any direct or indirect financial interest in the business or any person holding a 1st, 2nd, or 3rd class license or druggist’s permit? Names of Licensee by whom applicant is employed? Address of employer’s principal place of business Does applicant have full time employment with the undersigned licensee? (If not, explain on separate paper) Do you agree to return your Solicitor’s Permit to your employer when you cease to be employed by him? in the State of Dated at this day of . I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes dues the State of Vermont as of the date of this application (VSA, T. 32, § 3113. I hereby certify that the information in this application is true and complete. Signature of applicant CERTIFICATE OF EMPLOYMENT (Must be completed and signed by a Certificate of Approval holder) license, hereby certifies that the above named is employed as a sales representative, and it is agreed that immediate notice will be forwarded and permit surrendered to the Liquor Control Board, Montpelier, Vermont if at any time he ceases to be so employed. I hereby recommend the above named applicant as being qualified to hold such a permit. The undersigned, being the holder of a (Licensee) (Licensee Number) (Signature of member of firm, officer of corporation or authorized agent) American LegalNet, Inc. www.FormsWorkflow.com