STATE WHERE DO YOU INTEND TO DO BUSINESS IN IONIA COUNTY:

_____________________________________________________

ADDRESS :____________________________________________

PHONE NUMBER:______________________________________

*NAME OF REPRESENTATIVE :__________________________

ADDRESS :____________________________________________

PHONE NUMBER:______________________________________

*If acting as Agent for another person, the Applicant shall cause to be file with the County Treasurer a POWER OF ATTORNEY, appointing the County Treasurer the Agent of Principal on whom service of process may be made in any suit commenced against the Principal.

DEPOSIT REQUIREMENTS

[   ] COPY OF MICHIGAN SALES TAX LICENSE

(Except for Applicant selling only food for human consumption)

SURETY BOND _________________       EXP. _______________

                             INSURANCE FIRM                         DATE

 $500.00  [   ] CASH    [    ] MONEY ORDER  [    ]  CASHIER’S CK.

[   ] $25.00 LICENSE FEE 

EXPIRES DECEMBER 31, ______

NOTE: Surety Bond or cash deposit shall be returned to merchant four months after expiration of license subject to any claims or judgments that may be properly field within Ionia County as provided in §4, PA 51, 1925

 ___________                 ______________________________________

   DATE                                        APPLICANT’S SIGNATURE