Application For Licensure To Hold Closed Circuit Telecasts Form - 1999 Page 2
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Have you or any of your officers or representatives ever been convicted of a felony or misdemeanor?
Yes
No
If "yes", when and where? (Give all particulars)
!
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Have you ever been suspended, penalized or disciplined by any commission or regulating department?
Yes
No
If "yes", when and where? (Give all particulars)
References for Person, Club, Corporation, Association or Organization (give three):
NAME
ADDRESS
!
!
Is there any pending violation of the Building Department, Health Department or the Fire Department?
Yes
No
First event date scheduled
Any false statement or misrepresentation made by an applicant on this form may result in denial or revocation of this license.
CLUB, CORPORATION, ORGANIZATION OR ASSOCIATION
NAME OF PERSON SIGNING APPLICATION AND TITLE
By
SIGNATURE
State of Washington
ss.
County of
On this ______________ day of ___________________________________________________________ , ______ ,
appearing before me personally came
to me known, and by me being duly sworn, did depose and sign this application with full knowledge of all information given
to be true and has the authority for signature on said application.
SIGNATURE
TYPE OR PRINT NAME
(SEAL)
Notary Public
Residing at
in said County.
My appointment expires
PA-611-011 CC TV APP. (R/11/99)M/W Page 2 of 3
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