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2. 
3. MOBILE FOOD ESTABLISHMENT LICENSE APPLICATION
5. First Name*
6. Middle Name
7. Last Name*
8. Former Name(s)
10. Address*
12. City*
13. State*
14. Zip Code*
16. Telephone*
17. Email
19. Date of Birth*
20. Place of Birth*
22. Driver's License #*
23. State*
25. Location of Sales*
27. Name/Address of Property Owner*
29. Date of Sales*
30. Items to be Sold*
32. Source of Supply Name/Loocation*
34. Vehicle Description/License Plate #*
36. If Employed, Name/Address/Telephone

38. Indicate last Cities/Villages (No More Than 3) Where Applicant Conducted Business Immediately Preceding Date of Application. List the Addresses from which such Business was Conducted

48. HAVE YOU EVER BEEN CHARGED WITH OR CONVICTED OF ANY CRIME, TRAFFIC VIOLATION, OR VIOLATION OF A MUNICIPAL ORDINANCE (Excluding parking tickets)? 

50. If YES, please provide the following: (Additional paper provided if needed)*

    1. Yes
    2. No
52. Date of Arrest
53. Arresting Agency
55. Offense
57. Date of Arrest
58. Arresting Agency
60. Offense
62. Date of Arrest
63. Arresting Agency
65. Offense
67. Signature*
68. Date*

72. Attach the Following Items:

74. A copy of your Driver’s License*
75. State Retail Food Permit*
77. Declaration page of insurance policy showing liability coverage.*
78. State Seller's Permit*
82. Received by
83. Date
84. Sent to PD
86. PD Approval
87. Denial
88. Date
Leave This Blank:


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

    This field is not part of the form submission.

92. Submit

* indicates a required field