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State of Alaska Business License - DOC

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					                          CITY OF FAIRBANKS
                          PAWNBROKER LICENSE APPLICATION
                          FGC Section 14.211-221

                                     APPLICATION REQUIREMENTS
□    Fee: New License Application (valid for 2 years)         PLUS                           500.00
          Investigation (each active owner, corporate officer, partner)                       75.00
            Renewal License Application (valid for 2 years) PLUS                             200.00
            Investigation (each active owner, corporate officer, partner)                      75.00
□    Copy of your current State of Alaska driver’s license OR State of Alaska State ID
□    Copy of your current State of Alaska Business license.
□    Criminal History Report must reflect a ten year history. Report for Alaska (APSIN) may be
       obtained from the Alaska State Troopers, other states please contact that state’s Department of
       Public Safety. NOTE: All reports must be current, APSIN report must be dated the same date
       that the completed application is submitted to the City Clerk’s Office.
        Note: Renewals require a history reflecting two years.

                IF YOUR CRIMINAL HISTORY DOES NOT REFLECT TEN YEARS,
                   YOU MUST ALSO PROVIDE THE FOLLOWING TWO ITEMS
           □ Background check from states you resided in other than Alaska
           □ Current driving record. from states you resided in other than Alaska
□    Two affidavits signed and notarized (see page 4 of application)
□    Completed Application

            Please note that all employees, owners, corporate officers, and partners that are
      actively engaged in the business must complete the Pawnbroker’s Employee Application and
      requirements prior to working, with the exception of the primary owner that is named below.
    APPLICANT:
    Name: First ________________M.I.______________Last___________________
          Other Names Used: ____________________________________________
    Current Address (Physical): ____________________________________________
    Address (Mailing): _____________________________________ ZIP __________
    HM Phone #: ___________ Alt. Phone #: ____________ Email:_______________
    Length of Time in Alaska: _________________Years _______________Months
    Previous City and State other than Alaska for the past 10 years:
    _________________________City and State ______________ Years and Months
    _________________________City and State ______________ Years and Months
    _________________________City and State ______________ Years and Months
    _________________________City and State ______________ Years and Months
    Sex: _____ Race:___________ Hair Color :_____ Eye Color: _____ Height: ____
    Weight: ____ Glasses: Y / N Place of Birth:_____________ Date of Birth_______
    Pawn Broker Application                            Revised 11-2004                    Page 1 of 4
BUSINESS:
    Complete Name:_______________________________________________
    Physical Address and Location ___________________________________
    _____________________________________________________________
    Mailing Address______________________________ZIP_______________
    Phone #: ___________ Alt. Phone #: _____________Fax #: ____________
    Email:___________________ AK Business License # _________________

OWNERS, CORPORATE OFFICERS, PARTNERS:                           (Attach additional sheet if necessary)

Name: First________________M.I.________Last _________________________
    Other Names Used: _____________________________________________
    Mailing Address______________________________ZIP_______________
    Occupation_______________DOB___________Citzenship:_____________

Name: First________________M.I_________Last _________________________
    Other Names Used: _____________________________________________
    Mailing Address______________________________ZIP_______________
    Occupation_______________DOB___________Citzenship:_____________

Name: First________________M.I._________Last ________________________
    Other Names Used: _____________________________________________
    Mailing Address______________________________ZIP_______________
    Occupation_______________DOB___________Citzenship:_____________

EMPLOYEES: (Attach additional sheet if necessary)
Name: First________________M.I._________Last ________________________
    Other Names Used: _______________________________DOB__________
    Mailing Address______________________________ZIP_______________

Name: First________________M.I._________Last ________________________
    Other Names Used: _______________________________DOB__________
    Mailing Address______________________________ZIP_______________

Name: First________________M.I._________Last ________________________
    Other Names Used: _______________________________DOB__________
    Mailing Address______________________________ZIP_______________

Name: First________________M.I._________Last ________________________
    Other Names Used: _______________________________DOB__________
    Mailing Address______________________________ZIP_______________

Pawn Broker Application                       Revised 11-2004                      Page 2 of 4
TERMS AND CONDITIONS OF LENDING AGREEMENT:
    Time allowed for redemption of merchandise:________________________
    Rate of interest charged: _________________________________________
    Other Charges:_________________________________________________
    Method of identifying articles for redemption:________________________
    _____________________________________________________________


      APPLICANT’S STATEMENT FOR PAWNBROKER’S LICENSE:
I, ________________________________________, being first duly sworn, depose and state that
I am the individual making application for license and that the answers to the foregoing
questions and other statements contained herein are true and complete to the best of my
knowledge and belief. I understand that any materially false statement on this application may
be subject to revocation or denial of license.

I certify that I read and write the English language.
I certify that I am 18 years of age or older.
►I certify that all persons connected with the ownership and operation of this business have
       been listed on this application and comply with all requirements for licensure.
I certify that the persons so listed on this application, including myself, have not been
       convicted of a felony, assault with a dangerous weapon, or a misdemeanor involving
       moral turpitude in the ten (10) years preceding the date of this application.
I certify that I have read and understand the FGC Section 14.211-221.
I certify that I have read the application and understand the requirements for licensure.

                                                       __________________________________
                                                             Signature of Applicant


Sworn to before me this ______________
Day of _____________________, 20___.
                                                                 (SEAL)
________________________________
NOTARY PUBLIC
My commission expires_______________.

The City Clerk’s office located at 800 Cushman Street, Fairbanks Alaska 99701 is open 9:00 am to 4:00
pm, Monday-Friday
********************************************
ADMINISTRATIVE USE ONLY:

Approved       Disapproved. Reason: __________________________________________________

Signature:__________________________________________                  Date: _____________________
Title:        City Clerk or   Deputy City Clerk




Pawn Broker Application                        Revised 11-2004                        Page 3 of 4
                                       AFFIDAVIT
I, _______________________________________________, do swear and affirm
that _____________________________________(Applicant) is of sound mind
and body, of good moral character, and is considered by me to be a respectable,
upstanding citizen to the best of my knowledge.

                                                ______________________________
                                                Signature
                                                ______________________________
                                                Print Name
(SEAL)                                          ______________________________
                                                Address



Sworn to before me this ________ day
Of ____________________, 20_____.

_______________________________
NOTARY PUBLIC
My commission expires____________.

                                       AFFIDAVIT
I, _______________________________________________, do swear and affirm
that _____________________________________(Applicant) is of sound mind
and body, of good moral character, and is considered by me to be a respectable,
upstanding citizen to the best of my knowledge.

                                                ______________________________
                                                Signature
                                                ______________________________
                                                Print Name
(SEAL)                                          ______________________________
                                                Address


Sworn to before me this ________ day
Of ____________________, 20_____.

_______________________________
NOTARY PUBLIC
My commission expires____________.
Pawn Broker Application                  Revised 11-2004            Page 4 of 4

				
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Description: State of Alaska Business License document sample