THE TOWN OF WYOMING BUSINESS LICENSE APPLICATION

DATE:_____________

The undersigned applicant, being duly and authorized by law to practice, conduct or carry
on the business of OUTSIDE CONTRACTOR,  hereby makes an application in accordance with
the ordinances of  the Town of Wyoming for a business  license  for a period of one ( 1 )
year beginning October 1, 2009 and submits herein the following information:

Applicant name (individual):_____________________________________________________________________

Applicants Address:___________________________________________________________________________

City:  ________________________ State ________________  Zip________________

Telephone :  Day ______________ Evening ______________

Business Name: ____________________________________________________________________________

Business Street address:_____________________________________________________________________

City:  ________________________ State ________________  Zip________________

Principal line of business:_________________________________________________

Has the applicant been convicted of any criminal act? If yes explain:__________________________________________________________________________________

Has the applicant ever had a license revoked and or suspended in the state
of Delaware or any other state?  If yes explain____________________________________________________

Is the business licensed with the State of Delaware and with any other regulatory office as required by their profession? __________  STATE: ____________ 

Lic. #______________________

AS A REQUIREMENT FOR THE TOWN OF WYOMING PLEASE ATTACH A CERTIFATE OF INSURANCE!

Applicant's Signature:_______________________DATE:_________________________

_________________________________________________________________________________________________________________________________

FOR OFFICE' USE ONLY
Date. Pd:______________    Amount:   _________________    Check:_______________ Cash:__________

License# issued:______________________________________

Town Clerk Signature:______________________________________         Date:_____________________