
FAIRFIELD POLICE
100 Reef Road, Fairfield, CT 06824 (203) 254-4840
PRECIOUS METAL DEALERS WEEKLY REPORT FORM
NAME:
DDRESS:
OWNER'S NAME:
TELEPHONE #:# STREET
FAIRFIELD, CT
REPORT FOR WEEK ENDING:
BUSINESS INFORMATION
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.
INSTRUCTIONS
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 OF SS.
Subscribed to and sworn before me on this ________ day of ___________________ 20_______.
NOTARY PUBLIC
commission expires:
PAGE:
OF
FPD-124
rev.11/08
THESE REPORTS MUST BE SUBMITTED TO THE FAIRFIELD POLICE DEPARTMENT WEEKLY.
FAILURE TO DO SO COULD RESULT IN THE DEALERS LICENSE BEING REVOKED.