PLEASE COMPLETE THIS REQUIRED INFORMATION FOR ADDITIONAL INDIVIDUALS THAT WILL BE WORKING THE EVENT FOR YOUR COMPANY.

TOWNSHIP OF MEDFORD

APPLICATION FOR SPECIAL EVENT SOLICITOR’S PERMIT

Name:

Company for which license is requested:

Permanent Home Address:

Permanent Business Address:

(if applicable)

Day Phone: ( ) Evening Phone: ( )

Cell Phone: ( ) Other Phone: ( )

Fax: ( ) E-Mail:

Social Security Number: Date of Birth:

TOWNSHIP OF MEDFORD

APPLICATION FOR SPECIAL EVENT SOLICITOR’S PERMIT

Name:

Company for which license is requested:

Permanent Home Address:

Permanent Business Address:

(if applicable)

Day Phone: ( ) Evening Phone: ( )

Cell Phone: ( ) Other Phone: ( )

Fax: ( ) E-Mail:

Social Security Number: Date of Birth: