TOWNSHIP OF MEDFORD

APPLICATION FOR REGISTRATION CERTIFICATE

PEDDLING AND SOLICITING PERMIT (L.O.113)

Length of Time Permit is Requested: Day Week Season

Dates:

Name:

Present Home Address:

Past Address (if present is less than 1 year):

Day Phone: ( ) Evening Phone: ( )

Cell Phone: ( ) Other Phone: ( )

Fax: ( ) E-Mail:

Social Security Number: Date of Birth:

Driver’s License Number: Place of Birth:

Age: Height: Weight: Race: Hair: Eyes: Married/Single

Present Occupation:

Place of Employment:

Duties:

Work Phone: ( ) Immediate Supervisor:

Name of Company for which Peddling/Soliciting is being conducted:

Company Address:

Company Phone: ( ) Immediate Supervisor:

Type of Business:

Brief Statement of Nature of Business:

Does Applicant require use of a noise-making device (bell, etc.)

TOWNSHIP OF MEDFORD

APPLICATION FOR REGISTRATION CERTIFICATE

PEDDLING AND SOLICITING PERMIT (L.O.113)

Merchandise Offered for Sale: Yes/No

Describe Merchandise:

Where is Merchandise/goods held presently?

Services Offered for Sale: Yes/No

Describe Services:

Solicitation of Funds: Yes/No

Describe where funds being routed/deposited: ________________________________________________

Is this company registered with New Jersey Department of Law & Public Safety, Division of Consumer Affairs as a Charitable Organization? Yes/No

List Actual Name as registered:

Description of Vehicle to be used: Year: Make:

Model: Color: Tag Number:

Three (3) business references located in the County of Burlington:

Name Address Telephone #

1.

2.

3.

Have you ever been convicted of any crime, misdemeanor or violation of any Municipal Ordinance? Yes/No

**NOTE** Falsification of material facts in this application is subject to
NJS 2C: 21-4: Falsifying or Tampering with Records

If yes, please describe, including nature of offense and penalty assessed.

Date Location Charge Disposition

TOWNSHIP OF MEDFORD

APPLICATION FOR REGISTRATION CERTIFICATE

PEDDLING AND SOLICITING PERMIT (L.O.113)

PHOTOGRAPH OF APPLICANT TAKEN WITHIN 60 DAYS TO BE PROVIDED WITH APPLICATION

(A copy of current driver’s license with picture is acceptable.)

1. ALL applicants MUST submit a CERTIFICATE OF INSURANCE showing proof of $1 million general liability insurance with the TOWNSHIP OF MEDFORD as the ADDITIONAL INSURED.

2. ALL FOOD MERCHANDISERS MUST submit a copy of applicant’s CURRENT HEALTH DEPARTMENT CERTIFICATE.

3. ALL applicable FIRE MARSHALL’S APPLICATION FOR PERMIT MUST be attached along with CHECK payable to “TOWNSHIP OF MEDFORD” in the amount of $25.00.

4. ALL applicants MUST submit a refundable DEPOSIT CHECK payable to “TOWNSHIP OF MEDFORD” in the amount of $100.00. This deposit will be returned after the event if all terms of this permit have been met.