SALVAGE DEALERS LICENSE REQUIREMENTS

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Please return all materials and application fee no later than December 20th. SALVAGE DEALERS LICENSE REQUIREMENTS LICENSE TERM: February 1st to January 31st 1. License fee of: $60.00 for 2017 2. Completed and signed City application form 3. Completed/signed Release of Information form. 4. Completed/signed Certification of MN Workers Comp Law form 5. $1,000 Surety Bond certificate 6. Completed and signed Tax Information form. 7. New Applicants only: Submit three Business or Personal Reference Sheets 8. Review/keep on file a copy of City Code Chapter 14, Article III Forward forms to the City of Faribault Administration Office: City of Faribault Attn: Carole Dillerud, Deputy City Clerk 208 First Avenue NW Faribault, MN 55021

SALVAGE DEALERS LICENSE APPLICATION City of Faribault, Minnesota ALL QUESTIONS MUST BE ANSWERED Amount Paid $ Date Paid I,, (Full Name) residing at, (Address) doing business as, (Name of Business) hereby apply for a Salvage Dealers License for the license period commencing February 1, and ending January 31,. Business is located at (Not PO Box) (Address) Business Phone Number within the City of Faribault, in accordance with Minnesota Statutes. Applicant will strictly comply with the Laws of the State of Minnesota governing salvage dealers regulations and laws of the City of Faribault. I certify that I have read the foregoing questions and the answers to said questions are true of my knowledge. Dated: Signature of Applicant --------------------------------------------------------------------------------------------------------- REPORT ON APPLICANT OR APPLICANTS BY POLICE DIVISION This is to certify that to the best of my knowledge, the applicant, named herein has not been convicted within the past five years for any violations of Laws of the State of Minnesota, or Municipal Ordinances relating to any crime concerning dishonesty, fraud, deceit or immorality except as hereinafter stated. Dated: Police Chief

City of Faribault RELEASE OF INFORMATION INFORMATION ADVISORY AND AUTHORIZATION FOR RELEASE OF INFORMATION TO SUPPORT LICENSE APPLICATION In connection with your application for a license, you are being requested to provide information regarding your criminal and financial background that may be classified as public or private data under the Minnesota Data Practices Act. The purpose of the information requested in the application is to provide background for the investigation of license applicants required by City Ordinance. Providing the information will assist the Police Department in preparing an Investigative Report for the City Council s review. The Investigative Report is given to the City Council and is used when granting or denying the license. All information provided in that report becomes part of the public record and is available to any interested individual. If the license is approved, all information provided by the applicant as part of the license application becomes public and is available to any interested individual. If the license is not approved, only the name and address of the applicant and the investigative report provided to Council for consideration becomes public. You have the right to refuse to supply the requested information. If you do so, this fact may be reported to the City Council and may result in the denial of your license. A criminal charge, arrest, or conviction will not bar an applicant from obtaining a license with the City of Faribault, unless the conviction is directly related to the matter for which the license is sought, according to MN Statute 364.03. However, failure to reveal the requested criminal information will be considered falsification of the application and may be used as grounds for the denial of the license. * * * * * * * * I acknowledge the above advisory and agree to provide the requested information. I further authorize the release to the City of Faribault of any information about my business and financial affairs, which may be requested from any firm relative to my financial background. I also authorize the City of Faribault to investigate the information provided in my application and to contact the persons named on the application. I understand that incorrect or incomplete information provided by me in my application may be considered falsification of the application and may be used as grounds for the denial of the license. _ Signature of Applicant Date _ Driver s License Number Date of Birth If not Minnesota, what State is Driver s License from:

Tax Information Form Form SP:C1 LICENSE APPLICANT: Pursuant to Minnesota Statutes, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department may supply this information to the Internal Revenue Service; 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following information and return along with your application to the agency issuing the licenses. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. License Applied For or Renewed Licensing Authority City of Faribault, 208 NW 1 st Avenue, Faribault, MN 55021 License Renewal Date APPLICANT S PERSONAL INFORMATION (if applicable): Name Street Address City, State, & Zip Code Social Security Number BUSINESS INFORMATION (if applicable): Business Name Street Address City, State & Zip Code Minnesota Tax ID Number* Federal Tax ID Number MN State Unemployment Compensation Tax # *If a Minnesota Tax Identification number is not required, please explain on the reverse side. (Check here) I certify that by checking this box I do not have any employees and therefore am not required to pay unemployment taxes. Signature Position (Owner, Officer, Partner, etc.) Date

City of Faribault AFFIDAVIT OF GOOD CHARACTER IN SUPPORT OF LICENSE APPLICATION RE: (Applicant(s) name, not business name) AFFIDAVIT I am personally acquainted with, and am not a relative of, the above-referenced applicant for a City of Faribault license. I have known the applicant personally, have observed his/her conduct for the past five years, and vouch for his/her honesty and general good character as a reputable citizen. I certify the foregoing statement is true to the best of my knowledge and belief. Signature of Affiant Date Print Full Name of Affiant Date of Birth of Affiant Street Address City State Zip Home Telephone # (include area code) (NOTE: Three of these forms are required.)

City of Faribault AFFIDAVIT OF GOOD CHARACTER IN SUPPORT OF LICENSE APPLICATION RE: (Applicant(s) name, not business name) AFFIDAVIT I am personally acquainted with, and am not a relative of, the above-referenced applicant for a City of Faribault license. I have known the applicant personally, have observed his/her conduct for the past five years, and vouch for his/her honesty and general good character as a reputable citizen. I certify the foregoing statement is true to the best of my knowledge and belief. Signature of Affiant Date Print Full Name of Affiant Date of Birth of Affiant Street Address City State Zip Home Telephone # (include area code) (NOTE: Three of these forms are required.)

City of Faribault AFFIDAVIT OF GOOD CHARACTER IN SUPPORT OF LICENSE APPLICATION RE: (Applicant(s) name, not business name) AFFIDAVIT I am personally acquainted with, and am not a relative of, the above-referenced applicant for a City of Faribault license. I have known the applicant personally, have observed his/her conduct for the past five years, and vouch for his/her honesty and general good character as a reputable citizen. I certify the foregoing statement is true to the best of my knowledge and belief. Signature of Affiant Date Print Full Name of Affiant Date of Birth of Affiant Street Address City State Zip Home Telephone # (include area code) (NOTE: Three of these forms are required.)

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