Shellfish Helper’s Permit
TC-13 rev. 11/19
A: RECEIPT NUMBER:
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9220
Fees: $50.00– Check Or Money Order Payable
To Donna Lent, Brookhaven Town Clerk.
B: HELPER'S PERMIT NUMBER: C: BUYER'S PERMIT NUMBER:
1. NAME OF APPLICANT : (HELPER)
2. HOME ADDRESS: (STREET) 3. CITY, STATE ZIP CODE:
4. BUSINESS NAME:
5. BUSINESS ADDRESS: (STREET) 6. CITY, STATE ZIP CODE:
7. TELEPHONE NUMBER: 8. DATE OF BIRTH: 9. AGE:
10. HEIGHT: 11. WEIGHT: 12. COLOR OF HAIR: 13. COLOR OF EYES:
14.
Are you an United States Citizen? Yes No
Description of vehicle used in connection with business:
15. YEAR: 16. MAKE AND MODEL: 17. LICENSE PLATE NUMBER:
18. NY STATE TAX ID NUMBER:
19. NY STATE DEC PERMIT NUMBER:
20. I certify that all information supplied is true and accurate and subject to a penalty for making a false
statement in violation of Section 210.45 of the Penal Law.
______________________
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APPLICANT’S SIGNATURE DATE
Each Commercial Buyer’s Helper Permit Application Shall Be Accompanied By:
The applicant’s employer’s commercial buyer’s permit
Two full-faced photos taken within 30 days (11/2 x 11/2)
Valid Photo Identification
