Corporate Name:      State of Incorporation:

Federal Identification Number:

Name:     Date of Birth:    Sex:

Social Security Number:Height:Weight:Eye Color:   Current Address:

Residence Address for Previous Five Years:

1)

2)

3)

4)

5)

Business Address Outside City of Plattsburgh:

                                                                           Business Phone Number:

Business Address in City of Plattsburgh:

                                                                           Business Phone Number:

Have you Ever Been Convicted of a Crime? Yes  No

If Yes, What Crime(s), Date(s), Place(s) of Conviction:

Crime(s)                                Date(s)                                Place(s)

How Long Have You Been a Dealer in Gold, Silver, and Other Precious Metals?:

At What Location:  

I understand that, if I violate any of the provisions of the "Ordinance regulating the sale in Gold, Silver, and other Precious Metals:, a copy of which I have received, I am subject to the penalties provided therein.

                                                                                                            ____________________________________

                                                                                                                    Signature of Applicant

                                                                   License Granted:                 ____________________________________

                                                                                                                    (Assistant) City Clerk