Application for Solicitor Permit - BADGE HOLDER

INFORMATION ON THIS APPLICATION IS PUBLIC RECORD

ATTENTION: Before completing this application, you will need the documents listed below saved to your computer and available to upload with this application.

TOTAL FEES DUE WITH THIS APPLICATION = $135.00
> Background Check Fee = $75.00
> Badge fee = $10.00
> Badge Deposit = $50.00

Any information you enter on this application will not be saved if you begin and return later.

* indicates required field
Attach a copy of valid driver's license or state issued photo identification*
Attach a current passport sized photo*
INFORMATION ABOUT BADGE HOLDER
Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Driver's License or State Issued ID #*
Issuing State*
Expiration Date*
MM
DD
YYYY
Physical Description
Height*
Weight*
Eye Color*
Hair Color*
Vehicle License Plate Number*
Enter 'N/A' if you don't have a vehicle
Vehicle Make, Model and Color*
Enter N/A if you don't have a vehicle
HAVE YOU BEEN RELEASED WITHIN THE TEN (10) YEARS IMMEDIATELY PROCEEDING THIS APPLICATION FROM ANY FORM OF INCARCERATION OR COURT-ORDERED SUPERVISION, INCLUDING A DEFERRED SENTENCE, RESULTING FROM A CONVICTION OF A FELONY OR CLASS 1 MISDEMEANOR UNDER THE LAWS OF THE STATE OF COLORADO OR AN EQUIVALENT OFFENSE UNDER ANY FEDERAL, STATE, COUNTY OR MUNICIPAL LAW?*
- Yes
- No
Provide Details
HAVE YOU BEEN CONVICTED OF BEING A SEXUALLY VIOLENT PREDATOR PURSUANT TO § 18-3-414.5, C.R.S.?*
- Yes
- No
Provide Details
ARE YOU A REGISTERED SEX OFFENDER UNDER THE COLORADO SEX OFFENDER REGISTRATION ACT?*
- Yes
- No
Provide Details
HAVE YOU BEEN CONVICTED OF A FELONY OFFENSE THAT WOULD REQUIRE REGISTRATION UNDER THE COLORADO SEX OFFENDER REGISTRATION ACT UNDER THE LAWS OF THE STATE OF COLORADO OR AN EQUIVALENT OFFENSE UNDER ANY FEDERAL, STATE, COUNTY OR MUNICIPAL LAW?*
- Yes
- No
Provide Details
INFORMATION ABOUT THE EMPLOYER
Name of Employer*
Employer's Phone Number*
Employer's Address*
Street Address Address Line 2 City State ZIP Code
Supervisor's Name*
First Last
Supervisor's Phone Number*
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENT OR OMISSION OF INFORMATION WILL BE CAUSE FOR LICENSE SUSPENSION, REVOCATION, OR GROUNDS FOR THE TOWN TO REFUSE TO ISSUE THE LICENSE.
Signed*
First Last
Date*
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Date Issued:______________________________________
Expiration Date:______________________________________

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