FAIRFIELD POLICE
100 Reef Road, Fairfield, CT 06824 (203) 254-4840
PRECIOUS METAL DEALERS WEEKLY REPORT FORM
THESE REPORTS MUST BE SUBMITTED TO THE FAIRFIELD POLICE DEPARTMENT WEEKLY.
FAILURE TO DO SO COULD RESULT IN THE DEALERS LICENSE BEING REVOKED.
ADDRESS: # STREET
FAIRFIELD, CT
INSTRUCTIONS
ALL INFORMATION ON THIS FORM SHALL BE EITHER TYPED OR LEGIBLY PRINTED. THE FRONT AND REAR OF THIS SHEET WILL BE FILLED OUT, SIGNED, AND NOTARIZED (SEAL REQUIRED). IF MORE THAN ONE PAGE IS UTILIZED FOR A WEEK, THE PAGES WILL BE CONSECUTIVELY NUMBERED. COMPLETE ONLY THE TOP SECTION OF PAGE ONE AND COMPLETELY FILL IN PAGE 2 OF ANY ADDITIONAL SHEETS.
On the reverse side of this form each and every transaction will be listed. This will include the date and time of the transaction, the ticket/receipt number (indicating pledge or sold), a complete description of the item or article (to include brand name, make, serial number, model number, and any other definitive markings or engravings), the Seller/Pledger's full name and residence as well as verifiable identification (such as motor vehicle operator's license) and a description of the Seller/ Pledger. The description SHALL include Race (W=White, B=Black, H=Hispanic, A=Asian, O=Other), date of birth, height, weight, eye color and hair color.
NOTARIZATION
The information contained on this form represents the total transactions completed by me for the week ending, as indicated above, in compliance with Chapter 409, Section 21-11 of the Connecticut General Statutes.
SIGNATURE OF DEALER / PAWNSHOP OPERATOR |
DATE |
STATE OF CONNECTICUT, COUNTY OFSS.
Subscribed to and sworn before me on this ________ day of ___________________ 20_______.
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NOTARY PUBLIC |
FPD-124 |
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rev.11/08 |
commission expires: |
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