Going Out of Business Sale License Application
TC-11 rev. 1/14
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
For Office Use Only
License #: Receipt #: Date Issued:
Close Out Sale, Defunct Business Sale, or Sales of Goods Damaged by Fire, Smoke or Water
1. TYPE OF SALE: 2. DATE OF SALE:
3. APPLICANT’S NAME: FIRST LAST
4. STREET ADDRESS: TOWN: STATE: ZIP:
5. ls the applicant an association or corporation?
If
ye
s, fill out 5A-5E. If no, go to 6. Yes No
5A. DATE AND PLACE OF INCORPORATION OR ORGANIZATION:
5B. ADDRESS OF PRINCIPAL OFFICE WITHIN NEW YORK STATE:
STREET ADDRESS: TOWN: STATE: ZIP:
5C. NAMES AND ADDRESSES OF ALL OFFICERS: (ATTACH ADDITIONAL SHEET IF NECESSARY)
_____________________________________ _____________________________________
_____________________________________ _____________________________________
5D. Is applicant the true owner of the
goods to be sold? Yes No
5E. Was controlling interest in the corporation or association
transferred within six months prior to filing this application? Yes No
6. LOCATION OF SALE:
7. LENGTH OF TIME BUSINESS HAS BEEN AT ADDRESS?
8. IS PREMISES OWNED OR LEASED?
Owned Leased
9. IF LEASED, TERMINATION DATE:
10. REASON FOR URGENT DISPOSITION OF GOODS:
11. NAME AND ADDRESS OF PERSONIPERSONS RESPONSIBLE FOR THE CONDUCT OF THE SALE:
_____________________________________ _____________________________________
12. IF CLOSE OUT SALE OR DAMAGED GOODS SALE, WlLL BUSINESS BE:
Terminate
d Permanently Resumed at the
Same Location
Moved to New Location
13. IF AT NEW LOCATION, DATE OF REOPENING:
14. NAME AND DESIGNATION UNDER WHICH NEW BUSINESS WILL BE RESERVED:
15. LIST TOTAL RETAIL VALUE OF GOODS
AND WARES TO BE OFFERED:
16. ATTACH AN ITEMIZED LIST OF THE GOODS FOR SALE INCLUDING
QUANTITY, BRAND NAME, AND MODEL NUMBER IF ANY
17. THE BOOKS AND RECORDS CONCERNING THE SALE ARE KEPT AT THE FOLLOWING ADDRESS:
STREET ADDRESS: TOWN:
STATE: ZIP:
IF THIS IS A RENEWAL APPLICATION, I CERTIFY THAT THE MERCHANDISE LISTED IN THE ORIGINAL INVENTORY HAS NOT BEEN
DISPOSED OF AND NO NEW MERCHANDISE HAS BEEN ADDED. IN ADDITION, I UNDERSTAND THAT IF ANY VIOLATION OF STATE
STATUTE REGARDING CHAPTER 169 OCCURS, IT MAY RESULT IN THE FORFEITURE OF LICENSE FEE.
Sworn to before me this ________ day of _____________ 20______.
________________________________________________________
NOTARY PUBLIC
17. SIGNA
TURE
:
UPON THE TERMINATION OF THE SALE, THE APPLICANT MUST, WITHIN 30 DAYS, FILE A STATEMENT WITH THE
TOWN CLERK STATING THE TOTAL RETAIL VALUE OF THE GOODS NOT DISPOSED OF DURING THE SALE AND THE
ULTIMATE DISPOSITION THEREOF; AND, IF TRANSFERRED TO ANOTHER, THE NAME, ADDRESS AND BUSINESS OF
THE TRANSFEREE. *FEES: $500 FOR FIRST APPLICATION AND $50 FOR RENEWAL.
