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City of Buckner
Peddlers Permit Application


$15.00 per 3 Day Period, Per Person

Name:     
Date of Birth:
Height: Weight:   
Social Security Number:    
Address:  
Local Phone Number


Permanent Phone Number


Nature of Business: 
If Produce, Type of Produce:    
Home Grown By Applicant:  Yes {  } No {  }

Employer:   
Employer’s  Address:
Phone Number:   
Credentials Verifying Employer: 
Length of Time for Which the Right to do Business is Desired:  
Vehicle Description:  
Year Make Model Color

Vehicle License Plate Number
Applicant’s Drivers License Number

Have you ever been convicted of any crime, misdemeanor, or violation of any municipal ordinance? Yes {  } No {  }

If Yes, State the Nature of the Offense and the Punishment or Penalty Assessed: