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Personal Information

Employer's Name
Employer's Address
City, State, Zip
Length of Service with Employer?*
Nature of Goods/Services Offered?*
List (3) locations, including addresses where applicant conducted business immediately preceding this application:
Method of Delivery?*
Vehicle Description*
License Plate Number?*
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Have you been convicted of any crime, misdemeanor, or violation relating in any way to your business within the last five years? *
1. Yes
2. No
If yes, list the nature of the offense(s) and the conviction, if any:
Date(s) requested to do business in Middleton:*
Place where applicant can be contacted for at least 7 days after leaving the city?*
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Please attach the following
Photograph (approx 2x2) showing head and shoulder of applicant not more than 1 year ago*
Driver's License*
Credentials establishing your relationship with your employer*
Example: a letter stating you own or work for the company
State certificate of examination and approval from the sealer of weights and measures (if applicable)
State Health Officer's Certificate (if applicant's business involves handling of food or clothing) dated not more than 90 days prior to application
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I attest that the above information is true and correct and that any false or incomplete information may result in denial of my application.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Initial here*
Please type name as shown on application above*
Date*
Date
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Fees & Payment
Once you hit submit, you will be directed to the credit card processing page. Application Fee: $50.00
No fee for Electronic Check Transfer
3.5% fee for credit card payments

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