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Secondhand Dealer/Pawnbroker Application

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This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Application Type(current) This section is complete This section is incomplete
2. Applicant Information This section is complete This section is incomplete
3. Owners, Employees, Officers, Directors, and/or Partners This section is complete This section is incomplete
4. Attestation This section is complete This section is incomplete
5. Payment This section is complete This section is incomplete

Application Type

City of Middleton Secondhand Dealer/Pawnbroker Application
Check all that apply*
1. Secondhand Article Dealer $50.00
2. Secondhand Textbook Dealer $50.00
3. Secondhand Jewelry Dealer $50.00
4. Secondhand Mall/Flea Market Dealer $50.00
5. Pawnbroker $500 ($500 bond required with not less than two sureties)
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Applicant Information

Name of Corporation, LLC, or Sole Proprietor*
Doing Business As*
Contact First Name*
Contact Last Name*
Phone Number*
E-mail address*
Address of where the license will be held*
City*
State*
Zip*
Describe the type of business and articles of merchandise to be handled*
State Seller's Permit Number*
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Owners, Employees, Officers, Directors, and/or Partners

List all owners, employees, officers, directors, and/or partners
Name
Upload DL/ID
Title
Phone Number
Address, City, State Zip
Have you been convicted of any of the following? (select all that apply)*
1. Felony (within the last 10 yrs)
2. Misdemeanor (within the last 5 yrs)
3. Statutory violation punishable by forfeiture (within the last 5 years)
4. County or municipal ordinance violation (within the last 5 years)
5. None
For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
Name
Upload DL/ID
Title
Phone Number
Address, City, State Zip
Have you been convicted of any of the following? (select all that apply)
1. Felony (within the last 10 yrs)
2. Misdemeanor (within the last 5 yrs)
3. Statutory violation punishable by forfeiture (within the last 5 years)
4. County or municipal ordinance violation (within the last 5 years)
5. None
For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
Name
Upload DL/ID
Title
Phone Number
Address, City, State Zip
Have you been convicted of any of the following? (select all that apply)
1. Felony (within the last 10 yrs)
2. Misdemeanor (within the last 5 yrs)
3. Statutory violation punishable by forfeiture (within the last 5 years)
4. County or municipal ordinance violation (within the last 5 years)
5. None
For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
Attach a separate sheet, if necessary.
Attach a separate file to list any additional owners, employees, officers, directors, and/or partners, or if you prefer, you may attach the information requested above as a file upload. Please be sure to include a copy of identification for each owner, employee, officer, director, and/or partner and to answer the conviction questions.
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Attestation

I understand that this license may be denied or revoked for fraud, misrepresentation or false statement contained in the application or for any violation of State Statutes 134.71, 943.34, or 948.63. Under Penalty of law, I swear that the information provided in this application is true and correct to the best of my knowledge. I agree to inform the Clerk within ten (10) days of any change in the information supplied in this 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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Payment

Payment
Once you hit submit, you will be directed to the credit card processing page.
No fees for Electronic Check.
3.5% for Credit Card Payment.

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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MIDDLETON | WI
7426 Hubbard Avenue Middleton, WI 53562 Phone: 608-821-8350
The City of Middleton is an Equal Opportunity Employer seeking a diverse and talented workforce.

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