Form Center

2. 
3. JUNK DEALER LICENSE APPLICATION
5. First Name*
6. Last Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Telephone*
15. Email
17. Date of Birth*
18. Place of Birth*
20. Driver's License #*
21. State*
23. Business Address*
25. City*
26. State*
27. Zip Code*
29. Business Telephone*
30. Lot/Parcel of Land upon which Materials are to be Collected, Stored or Delievered*
32. Type of Materials Accumulated or Gathered*
34. Are these Materials Combustible*

    1. YES
    2. NO
36. Signature*
37. Date*

41. FEES:

    $20.00 For maintaining Junk Yard, Warehouse or other Place for Storage or Junk.
     $5.00 For Gathering Junk by means of a Wagon, Cart or other Vehicle.
     $5.00 Per Day, Itinerant Dealer or Gather.

43. Received By
44. Date

46. Code Enforcement

48. Inspector
49. Date of Inspection
Leave This Blank:


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

    This field is not part of the form submission.

53. Submit

* indicates a required field