HomeMy WebLinkAboutpawn_secondhand_applicationDepartment of Agriculture,
Trade and Consumer Protection
CP-121 (rRAC-433), 4/08
State of Wisconsin
(WI Slat. 134.71)
LICENSE APPLICATION
for
PAWNBOKER
SECONDHAND JEWELRY DEALER
SECONDHAND ARTICLE DEALER
SECONDHAND ARTICLE DEALER MALL/FLEA MARKET
❑ Original application 0 Renewal
TYPE: 0 Pawnbroker 0 Secondhand Jewelry Dealer
0 Secondhand Article Dealer ❑ Mall/Flea Market
INSTRUCTIONS:
INDIVIDUAL LICENSE — Complete Sections 1, 2, 3 and 6
PARTNERSHIP LICENSE — Complete Sections 1, 2, 3, 4 and 6
CORPORATE LICENSE — Complete Sections 1, 2, 3, 5, and 6
Have you, or any other person listed on this application, been convicted of any of the following:
A FELONY WITHIN THE LAST TEN (10) YEARS? ❑ YES O NO
WITHIN THE LAST FIVE (5) YEARS OF:
a misdemeanor? ❑ YES ❑ NO
a statutory violation punishable by forfeiture? O YES O NO
a county or municipal ordinance violation? O YES O NO
For each "YES" response provide the date of arrest, the nature of the offense and conviction information:
Business Name
Street Address
City
State
ZIP
Telephone Number
Owner's Name
Street Address
City
State
ZIP
Telephone Number
Business Manager's Name
Street Address
City
State
ZIP
Telephone Number
Building Owner's Name
Street Address
City
State
ZIP
Telephone Number
(Over)
• •- •
Partnership Name:
List name, address, sex, race and date of birth (DOB) of all partners. Attach additional sheets if necessary.
Name (Last, First, MI)
Sex
Race
DOB
Street Address
City
State
ZIP
Corporation Name: State of
Incorporation:
List name, address, sex, race and date of birth (DOB) of all corporation officers and directors. Attach additional sheets if necessary.
Name (Last, First, MI)
Sex
Race
DOB
Street Address
City
State
Zip
I understand that this license may be denied or revoked for fraud, misrepresentation or false statement contained in
the application or for any violation of Wis. Stats. §§ 134.71, 943.34, 948.62 or 948.63.
Under penalty of law, I swear that the information provided in this application is true and correct to the best of my
knowledge. I agree to inform the clerk within ten (10) days of any change in the information supplied in this
application.
Signature of Applicant:
Print Name of Applicant: