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CITY/TOWN OF:  

 

APPLICATION FOR PAWNBROKER LICENSE

 

  In accordance with Maine statutes, Title 30-A M.R.S.A. §3961, the undersigned hereby applies for a License to conduct pawn transactions.

 

Please print clearly or type

 

1.  COMPANY NAME: _____________________________________________________________   

 

2.                   COMPANY ADDRESS:  

 

 

Street  City/Town  State  Zip Code 

 

 

3.  TELEPHONE: ______________________  ______________________    Day    Evening/Weekend 

 

 

4.  LOCATION OF RECORDS: __________________________________________________________   

 

5.  BUSINESS STRUCTURE:

 

[  ] PROPRIETORSHIP  [  ] PARTNERSHIP  [  ] CORPORATION

 

PROPRIETORS, PARTNERS, OR DIRECTORS:

 

 

Name  Address  Telephone

 

 

Name  Address  Telephone

 

 

 

Name  Address  Telephone

 

 

 

Name  Address  Telephone

 

CERTIFICATION

 

I hereby certify that the above statements are true and correct to the best of my knowledge and belief.

 

Dated this   day of   , 20  .

 

 

Signature   

 

 

Name typed or printed legibly 

 

 

 

 

Title 

 

Return to the Municipal Offices with the proper fee of $