Ordinance No. 27-99
1
TO BE COMPLETED BY PRESIDENT OF CORPORATION
OR PRINCIPAL PARTNER OR OWNER
__________________________________________
CITY OF DANIA BEACH
APPLICATION FOR GARBAGE COLLECTION PERMIT
INSTRUCTIONS:
1. WARNING: Read carefully, this instrument is a sworn document. False answers
could result in criminal prosecution, subject to fine and/or imprisonment.
2. Form must be typed or printed legibly in ink.
3. Each question must be answered completely. If not applicable, indicate same as
N/A.
4. Form must be sworn and subscribed to before a Notary Public.
Failure to comply with the instructions will require a return for corrections
thereby causing considerable delay in the processing of the application.
$_____________ DATE: _______________
I hereby make application for a permit to conduct the business of
________________________________________________________________________
(Name of business) (Address of business)
NAME _________________________________________________________________
(Last) (First) (Middle)
DATE OF BIRTH_____________PLACE OF BIRTH____________________________
(City) (State) (County)
SOCIAL SECURITY NO.__________________ HOME PHONE NO._______________
DRIVERS LIC. NO.______________________ BUS. PHONE NO. ________________
SEX________RACE_________EYES_________WEIGHT_________HEIGHT_______
Ordinance No. 27-99
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If business is a partnership, list name and home address of all persons having an interest
therein, and the percentage of interest. (Attach Personal Data Sheet for each partner.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If application is for a corporation, list title if corporation, as registered with the Secretary
of State. (If not a Florida Corporation, list State in which incorporated.)
________________________________________________________________________
List name of all other officers of the corporation, giving name, title, home address and
number of shares/stock owned. (Attach Personal Data Sheet for each officer.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you, in the past or presently, individually or as an officer of a corporation, held a
garbage collection permit in the City of Dania Beach?________ If yes, list names and
full addresses of all business
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever been convicted of a felony for violation of antitrust, anticompetitive,
racketeering or fraudulent practices during the past ten (10) years? _______ If yes, give
details as to date, place of arrest, arresting agency, nature of the offense, deposition of
case.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you involuntarily withdrawn service from any city or county during the five (5)
years period immediately preceding this application? _________ If yes, list cities and/or
counties and state reasons. (Attach additional sheet, if necessary)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you held any franchise which has been suspended or revoked during the five (5)
year period immediately preceding this application?______________ If yes, list
Ordinance No. 27-99
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franchisor and reasons for suspension or revocation. (Attach additional sheet, if
necessary.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Number of customer accounts currently serviced in Dania Beach.___________________
Number of collection vehicles available to serve this accounts._____________________
Do you maintain public liability insurance in an amount of $500,000 or greater?_______
If yes, attach certificate insurance.
Do you have sufficient maintenance ability to meet the service needs of the number of
trucks and equipment to be used to service accounts in Dania Beach? ________________
Person to be contacted regarding compliance with Section 13-74, Dania Beach, City Code.
Name: __________________________________________________________________
Address: __________________________________________________________
Telephone: _______________________________
The undersigned individually, or if a corporation for itself, its officers and directors,
hereby authorize the City Manager and/or the Broward Sheriff’s Office. District 2 to
conduct an investigation into information contained herein related to criminal or personal
records.
I agree to comply with all provisions contained in Section 13-74, “Garbage Collection by
Private Haulers”, Dania Beach City Code.
“I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY AS PROVIDED FOR IN
FLORIDA STATUTES 837.01, THAT THE FOREGOING INFORMATION IS TRUE
TO THE BEST OF MY KNOWLEDGE.”
I understand that some personal data answers are NOT MANDATORY and I hereby
WAIVE ALL OBJECTIONS TO THIS INFORMATION BEING SUBMITTED.
_____________________________
(Signature of Applicant)
SWORN TO AND SUBSCRIBE BEFORE ME THIS _____ DAY OF _________, 20__.
PERSONALLY KNOWN_____ OR PRODUCED IDENTIFICATION.
TYPE OF IDENTIFICATION PRODUCED: _______________________________
MY COMMISSION EXPIRES: _____________________
NOTARY PUBLIC: ______________________________ (SEAL)
*ATTACH NOTARIZED COPY OF TITLE OF CORPORATION, AS
REGISTERED WITH THE SECRETARY OD STATE.
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Ordinance No. 27-99
4
TO BE COMPLETED BY OTHER OFFICERS
OF CORPORATION OR OTHER PARTNERS
__________________________________________
PERSONAL DATA INFORMATION
Please see “Application for Permit” for instructions.
RE: APPLICATION FOR PERMIT OF _________________________________
(Name of Business)
NAME _________________________________________________________________
(Last) (First) (Middle)
DATE OF BIRTH_____________PLACE OF BIRTH____________________________
(City) (State) (County)
SOCIAL SECURITY NO.__________________ HOME PHONE NO._______________
DRIVER’S LIC. NO.______________________ BUS. PHONE NO. ________________
SEX_____RACE_______EYES_______ HAIR______WEIGHT_______HEIGHT_____
Have you, in the past or presently, individually or as an officer of a corporation held a
garbage collection permit in the City of Dania Beach?________ If yes, list names and
full addresses of all business
________________________________________________________________________
________________________________________________________________________
Have you ever been convicted of a felony for violation of antitrust, anticompetitive,
racketeering or fraudulent practices during the past ten (10) years? _______ If yes, give
details as to date, place of arrest, arresting agency, nature of the offense, deposition of
case.
________________________________________________________________________
________________________________________________________________________
Have you involuntarily withdrawn service from any city or county during the five (5)
years period immediately preceding this application? _________ If yes, list cities and/or
counties and state reasons. (Attach additional sheet, if necessary)
________________________________________________________________________
________________________________________________________________________
Have you held any franchise which has been suspended or revoked during the five (5)
year period immediately preceding this application?______________ If yes, list
franchisor and reasons for suspension or revocation. (Attach additional sheet, if
necessary.)
Ordinance No. 27-99
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________________________________________________________________________
________________________________________________________________________
The undersigned individually, or if a corporation for itself, its officers and directors,
hereby authorize the City Manager and/or the Broward Sheriff’s Office. District 2 to
conduct and investigation into information contained herein related to criminal or
personal records.
I agree to comply with all provisions contained in Section 13-74, “Garbage Collection by
Private Haulers”, Dania Beach City Code.
“I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY AS PROVIDED FOR IN
FLORIDA STATUTES 837.01, THAT THE FOREGOING INFORMATION IS TRUE
TO THE BEST OF MY KNOWLEDGE.”
I understand that some personal data answers are NOT MANDATORY and I hereby
WAIVE ALL OBJECTIONS TO THIS INFORMATION BEING SUBMITTED.
_____________________________
(Signature of Applicant)
SWORN TO AND SUBSCRIBE BEFORE
ME AT _______________________________
THIS_______ DAY OF ___________ 20____
______________________________________
(Signature of Notary Public – State of Florida)
______________________________________
Print, Type or Stamp Name of Notary Public
________ Personally known to me, or
________ Produced identification: ____________________
(Type of Identification)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PERMIT APPROVED: ___________________________________ DATE: __________
Fernando J. Rodriguez, Director of Public Services
PERMIT DENIED: ______________________________________ DATE: __________
Fernando J. Rodriguez, Director of Public Services
(Attach to application for Permit)
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