Shellfish Buyer’s Permit
TC-14 rev. 11/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
OFFICE USE ONLY
Fee: $300 – Check Or Money Order
Payable To Donna Lent, Brookhaven Town Clerk.
Permit Number: Receipt Number:
1. Name Of Applicant:
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. Citizen Of The USA:
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 ID Number:
20. Have You Had Any Criminal Proceedings Ever Commenced Against You? If Yes State The Nature And Disposition:
21. 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.
_____________________________________________________________ _________________________________
APPLICANT’S SIGNATURE DATE
Each Commercial Buyer’s Permit Application Shall Be Accompanied By:
A NYS Department Of Environmental Conservation Shellfish Shipper’s Or Processor’s Permit
NYS Sales Tax Certificate
Two full-faced photos taken within 30 days (11/2 x 11/2)
Valid Photo Identification
