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2. 
3. City of Middleton - Direct Sellers Registration Application
5. First Name
6. Last Name
8. Address1
10. City
11. State
12. Zip
14. Phone Number
15. E-mail address
17. Employer's Name
19. Employer's Address
21. City
22. State
23. Zip
25. Length of Service with Employer?*
26. Nature of Goods/Services Offered?*
28. List (3) locations, including addresses where applicant conducted business immediately preceding this application:
30. Method of Delivery?*
32. Vehicle Description*
33. License Plate Number?*
35. Have you been convicted of any crime, misdemeanor, or violation relating in any way to your business within the last five years? *

    1. Yes
    2. No
37. If yes, list the nature of the offense(s) and the conviction, if any:
39. Date(s) requested to do business in Middleton:*
41. Place where applicant can be contacted for at least 7 days after leaving the city?*
43. Attachments
45. Photograph (approx 2x2) showing head and shoulder of applicant not more than 1 year ago*
46. Driver's License*
48. Credentials establishing your relationship with your employer*

    Example:  a letter stating you own or work for the company

50. State certificate of examination and approval from the sealer of weights and measures (if applicable)
52. State Health Officer's Certificate (if applicant's business involves handling of food or clothing) dated not more than 90 days prior to application
54. Payment Method*

    1. Online
    2. Mailing Check

    Once you hit submit, you will be directed to the credit card processing page.  You may also mail a check to our office at 7426 Hubbard Avenue, Middleton, WI  53562.

58. I attest that the above information is true and correct and that any false or incomplete information may result in denial of my application.
60. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
61. Initial here*
63. Please type name as shown on application above*
64. Date*
    Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field