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2. 
3. City of Middleton Secondhand Dealer/Pawnbroker Application
5. Check all that apply*

   1. Secondhand Article Dealer
   2. Secondhand Textbook Dealer
   3. Secondhand Jewelry Dealer
   4. Secondhand Mall/Flea Market Dealer
   5. Pawnbroker ($500 bond required with not less than two sureties)
7. License Applicant
9. Name of Corporation, LLC, or Sole Proprietor*
10. Doing Business As*
12. Contact First Name*
13. Contact Last Name*
15. Phone Number*
16. E-mail address*
18. Address of where the license will be held*
20. City*
21. State*
22. Zip*
24. Describe the type of business and articles of merchandise to be handled*
25. State Seller's Permit Number*
27. List all owners, employees, officers, directors, and/or partners
29. Name
30. Title
31. Upload DL/ID
33. Phone Number
34. Address, City, State Zip
36. 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)
38. For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
42. Name
43. Title
44. Upload DL/ID
46. Phone Number
47. Address, City, State Zip
49. 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)
51. For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
55. Name
56. Title
57. Upload DL/ID
59. Phone Number
60. Address, City, State Zip
62. 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)
64. For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
68. Name
69. Title
70. Upload DL/ID
72. Phone Number
73. Address, City, State Zip
75. 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)
77. For each "yes" response above, please provide year of arrest, nature of offense, and conviction information. If none, type "none".
81. 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.

83. Payment Method*

    1. Online

    1. Mailing Check

    Once you hit submit, you will be directed to the credit card processing page.  You may also mail a check to our office at 7426 Hubbard Avenue, Middleton, WI  53562.

87. 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.
89. 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.
90. Initial here*
92. Please type name as shown on application above*
93. Date*
    Date
Leave This Blank:


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

    This field is not part of the form submission.

97. Submit

* indicates a required field