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2. Name of Business or Organization*
4. Sales Tax Number*
6. $500 Surety Bond Filed*
   $500 Surety Bond Filed
7. Upload Surety Bond*

   Certificate Holder must be City of Portland

9. Owner First Name*
10. Owner Last Name*
12. Address*
14. City*
15. State*
16. Zip Code*
18. Description of Business and Goods to be Sold*
20. Dates of Business or Solicitations *
    Dates of Business or Solicitations Start Date

    —

    Dates of Business or Solicitations End Date
22. Representatives Making Sales or Solicitations
24. Valid Photo Identification must be Uploaded for ALL Representatives**
26. First Name*
27. Last Name*
29. Address*
31. City*
32. State*
33. Zip Code*
35. Description of Vehicle: Color/Make/Model *
37. License Plate Number*
38. State Issued*
39. Owner of Vehicle*
41. First Name
42. Last Name
44. Address
46. City
47. State
48. Zip Code
50. Description of Vehicle: Color/Make/Model
52. License Plate Number
53. State Issued
54. Owner of Vehicle
56. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
58. Electronic Signature*
59. Completion Date*
    Completion Date
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field