Glendale Secondhand Permit Application

							City of Glendale                      Application for Second Hand Permit
Office of the City Clerk               GMC Code Sections 5.68.010-5.68.150
p 13 E. Broadway, Room 110
Glendale, CA 91206
818-548-2090                                                        Application Fee: $50.00
                                                                    License Fee: $200.00 (upon approval)
First Application _ _                                               Requirements:
Renewal _ _                                                                Personal Affidavits: Yes
Permit #: SEP_ _                                                           Photographs: New Applications Only
                                                                           Fingerprints: New Applications Only
Date: _ _ _ _ _ _ __

Business Name:_ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ __ _

Add ress:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~-----------_--
                      (street)                                      (city)                             (zip)
Phone:_ _ _ _ _ _ _ _ _ _ _ Hours of Operation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __


Ownership:          Individual- -     Partnership_ _   Corporation __
      Individual:   Name:
                    Home Address:
                    City and Zip:                                            Phone:
      Partnership: Name:
                    Home Address:
                    City and Zip:                                            Phone:
                    Name:
                    Home Address:
                    City and Zip:                                            Phone:
                    Name:
                    Home Address:
                    City and Zip:                                            Phone:
      Corporation: Officer's Name:
                    Home Address:
                    City and Zip:                                            Phone:
                    Officer's Name:
                    Home Address:
                    City and Zip:                                            Phone:
                    Officer's Name:
                    Home Address:
                    City and Zip:                                            Phone:
Manager or Person in Charge:
                    Name:
                    Home Address:
                    City and Zip:                                            Phone:

                                           (continued on reverse)
Have you or any partnership or corporation of which you were a member or officer had any license or permit
denied, suspended or revoked by any state, territory or governrnental agency? _ _ _ _ _ _ _ _ _ __

If you answered "Yes" to the preceding question, attach a supplementary statement giving a complete and
detailed explanation, including dates, names used, license or permit numbers, reasons and convictions. Any
plea of nolo contendre must be disclosed.

                         ATTACH COMPLETED SUPPLEMENTARY PAGE IF REQUIRED
•••••••••••••••••••••••••••••••••••••••••••••••••••••• ••• • • •• • • • •• • ••••••••••••• • •••• • • • • • •

       I have read and understand the provisions, rules and regulations of the City of Glendale, California and
the Municipal Code governing the type of license or permit for which I am applying .

       I declare under penalty of perjury that all of the information contained in this application and any
accompanying documents is true and correct, with full knowledge that all statements made in this form are
subject to investigation . Any false or dishonest answer to any question may be grounds for denial or
subsequent revocation of license or permit.



                                                                                  (signature)



                                                                                    (title)



                                                                                    (date )




SUBSCRIBED AND SWORN TO BEFORE ME THIS, _ _ _ _ ,DAY OF_ _ _ _ _ _ _ _ _ _ __




  (Notary Public or any other person authorized to
   administer oaths.)
                   .            CITY OF GLENDALE
                                                        •
                                                     818·548-%090



                   PERSONAL AFFIDAVIT IN SUPPORT OF APPLICATION

 PLEASE PRINT OR TYPE                                                 DATE: _ _ _ _ _ _ __



 FULLNAME_ _ _ _ _ _ _ _ _~-------~~~----
        . Last            First    Middle

                                                                                HOME
 RESIDENCE~----------~=_------~~~~.PHONE~(~)-----
                Street                         City .               State/Zip

                                                  BUSINESS
                                                  P
 BUSINESS-,_ _ _ _ _ _ _ _ _ _ _ _ _ _-,-----,--,-. HONE ( ),___,:",
          Street           City        State/Zip

 DESCruPTION~~~~-~--~--~--~77~~-~~~------
                  Date of Birth       Sex    Hgt. Wgt.         Hair Color       Eye Color


 DRIVER'S LICENSE NO._____________,SOCIAL SECUruTY________________

 List any and all other names used for legal iden~ification:




 Have you ~ been convicted ofa felony andlor misdemeanor? Ifans;ver is "YES" list the dates, specify the
 conviction, and identify the court and case number.



. I HAVE READ AND UNDERSTAND THE PROVISIONS, RULES AND REGULAnONS OF
  THE CITY OF GLENDALE, CALIFORNIA AND THE MUNICIPAL CODE GOVERNING
  THE TYPE OF LICENSE OR PERMIT FOR WHICH I AM APPLYING.
                            .         .

                                               Organization: _ _ __ _ _ _ _ _ ___

                                                      Signed: _ __ _ __ _ _ _ __

                                                        Title:--'-_ _ _ _ _ _ _ _ _ __


 K-182 (Rev. 711 8/05)