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4. Application for a Peddler's Permit
   I, the undersigned, hereby apply to the City of Poplar Bluff, Missouri, for the license above described and for the purpose of inducing the City of Poplar Bluff to issue me said permit pursuant to the City of Poplar Bluff Code of Ordinances, Section 610.060 which states that it shall be unlawful for any person to engage in business as a peddler within the City without first having applied for and obtaining a permit to do do from the City Clerk. I make the statements and answers hereinafter set out and understand and agree that, if any statements or answers made herein are untrue and the permit herein applied for is granted, such permit may be revoked or suspended by said City of Poplar Bluff and I further understand and agree that if I shall violate the provisions of any law of the City of Poplar Bluff, or of the State of Missouri, the City of Poplar Bluff may suspend or revoke the permit granted hereunder.
6. First Name
7. Last Name
9. Address
11. City
12. State
13. Zip Code
15. Business Name
17. Address
19. Does said business have a current business license in the city which said business is based?

    1. Yes

    1. No
21. Please list city where license is held.
23. Phone number of said company
24. Phone number of applicant
26. Kind of goods offered for sale
28. Origin of goods (i.e. purchased from retail outlet, purchased at estate sales, etc)
30. How long will applicant be engaged in said business in the City of Poplar Bluff?

    1. Per Day $5.00/Day
    2. Per Week $15.00/Week

    1. Per Month $50.00/Month
    2. Per Year $300.00/Year
32. Previous five (5) cities the applicant has solicited prior to coming to the City of Poplar Bluff?
34. Has applicant ever been convicted of any crimes other than a minor traffic violation?

    1. Yes

    1. No
36. If yes, give the place and court in which conviction was obtained and the sentence imposed and the result of such conviction.
38. Vehicle Information (Make, Model, Year, and Color)
40. License Plate Number
42. Where is applicant residing while in Poplar Bluff?
44. Phone number of place of residence? (Not a cell phone number)
46. Disclaimer
    Pursuant to the City of Poplar Bluff Code of Ordinances Section 610.070 the Office of the City Clerk shall issue said Peddler’s Permit within eight (8) business hours upon completion of the application. Photo ID of applicant and a license plate number are also required for issuance of Peddler’s Permit.
48. Signature

    1. Check Here

    By checking this box, I authorize my signature.
50. Residence Address
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field