Name

Local Street Address

Local Phone Number

This shall be address & telephone number at which the applicant can be reached locally for the time during which business is to be conducted in the City. If this address changes, the City shall be notified in writing. Failure to do so is grounds for revocation. This shall be address & telephone number at which the applicant can be reached locally for the time during which business is to be conducted in the City. If this address changes, the City shall be notified in writing. Failure to do so is grounds for revocation.

Kansas Sales Tax Certificate Number - Proof of Exemption

Other Applicant Information Other Applicant Information

Drivers License Number (attach copy at the bottom of the form)

State

Expiration Date

Today's Date

Height

Weight

Hair Color

Eye Color

Describe the nature of the business you intend to conduct. Include the description of goods to be sold, where goods are located at time of making application, method of sale, timing of delivery and payment, etc. In the event such goods or products are of farm or orchard, please indicate if they were grown or produced by the applicant or other parties. Describe the nature of the business you intend to conduct. Include the description of goods to be sold, where goods are located at time of making application, method of sale, timing of delivery and payment, etc. In the event such goods or products are of farm or orchard, please indicate if they were grown or produced by the applicant or other parties.

If applicant is employed by other than the previously identified corporation or organization, please provide name and address of the employer: If applicant is employed by other than the previously identified corporation or organization, please provide name and address of the employer:

Name

Street

City, State, and Zip Code

Phone Number

If motor vehicles are used, please provide the following information: If motor vehicles are used, please provide the following information:

Vehicle Number

Make & Model

Year

Color

Vehicle License Number

State

Vehicle Number

Make & Model

Year

Color

Vehicle License Number

State

If additional salesperson are used, please list, including name, address, drivers license number, and date of birth for each. If additional salesperson are used, please list, including name, address, drivers license number, and date of birth for each.

Name

Address

Driver's License Number

Date of Birth

Permit Number

Name

Address

Driver's License Number

Date of Birth

Permit Number

Name

Address

Driver's License Number

Date of Birth

Permit Number

Please indicate the period of time for which the right to do business is desired: Please indicate the period of time for which the right to do business is desired:

Please provide the names of two (2) reliable property owners of the City of Columbus, Kansas, who will certify as to the applicant’s good character and business responsibility: Please provide the names of two (2) reliable property owners of the City of Columbus, Kansas, who will certify as to the applicant’s good character and business responsibility:

Name

Name

Street

Street

City, State, and Zip Code

City, State, and Zip Code

Phone Number

Phone Number

In lieu of references, please provide other available evidences as to the character and business reasonability of the applicant. In lieu of references, please provide other available evidences as to the character and business reasonability of the applicant.

Applicant Signature

Date