Fill in as much information as possible to expedite review of your application.
Type of Permit: —Please choose an option—Peddler's PermitCanvasser's Permit
Applicant's (Peddler/Canvasser) FULL name
E-mail Address
HOME Street Address (number and street name)
City
State
Zip Code
County
Preferred phone number for immediate contact
Date of Birth
** Input the following ID information. You will also be required to upload a copy below ** Driver's License or State-issued ID Number
Driver's License or ID State
List the most recent 3 cities, towns, or counties in which you have conducted business activities similar to those you are requesting a Johnson County permit for:
Have you ever been convicted of a felony or misdemeanor? —Please choose an option—YesNo
If yes, list the offenses, date, location, and offense classification below ONE PER LINE (e.g. "Shoplifting, January 2018, Columbus OH, Level 1 misdemeanor")
Are you required to register as a sex offender or serious violent offender in Indiana or any other state? —Please choose an option—YesNo
Has a civil judgement ever been entered against you as a result of fraud, deceit, or breach of contract? —Please choose an option—YesNo
If yes, provide details including date and nature of judgement:
BUSINESS INFORMATION Business Name
Business Type —Please choose an option—Sole ProprietorshipPartnershipLLCCorporation
State of Business Formation or Registration
Tax ID (Social Security Number if none)
Business Street Address (number and street name)
Business City
Business State
Business Zip Code
Supervisor Name
Supervisor's phone number for immediate contact
Nature of business (e.g. Pest control, lawn care, maintenance, etc)
Description of goods/services to be offered; nature of information sought:
VEHICLE INFORMATION - List the vehicle you will be driving Make
Model
Color
Vehicle Year
Plate Number
__________________________________ ELECTRONIC SIGNATURE AGREEMENT __________________________________ By typing your name in the following field, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the Johnson County Sheriff's Office or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and the Johnson County Sheriff's Office. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your information and that such persons will be bound by the terms of this Agreement. You further agree that each use of your E-Signature constitutes your agreement to be bound by the terms and conditions of the Johnson County Sheriff's Office.
I hereby authorize the Johnson County Sheriff's Office to perform a criminal background check to verify information disclosed on this application. I AFFIRM, UNDER THE PENALTY OF PERJURY, THAT THE REPRESENTATIONS AND ANSWERS IN THIS APPLICATION ARE TRUE. Upload a copy of the front of your driver's license or other state-issued identification
