CITY/TOWN OF:

APPLICATION FOR PAWNBROKER LICENSE

In accordance with Maine statutes, Title 30-A M.R.S.A. §3961, the undersigned hereby applies for a License to conduct pawn transactions.

Please print clearly or type

1. COMPANY NAME: _____________________________________________________________

2. COMPANY ADDRESS:

Street City/Town State Zip Code

3. TELEPHONE: ______________________ ______________________ Day Evening/Weekend

4. LOCATION OF RECORDS: __________________________________________________________

5. BUSINESS STRUCTURE:

[ ] PROPRIETORSHIP [ ] PARTNERSHIP [ ] CORPORATION

PROPRIETORS, PARTNERS, OR DIRECTORS:

Name Address Telephone

CERTIFICATION

I hereby certify that the above statements are true and correct to the best of my knowledge and belief.

Dated this day of , 20 .

Signature

Name typed or printed legibly

Title

Return to the Municipal Offices with the proper fee of $