Fill - Free fillable CITY OF DANIA BEACH APPLICATION FOR GARBAGE COLLECTION (City of Dania Beach) PDF form

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._______________

DRIVER’S 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

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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