Shellfish Permit Application
TC-15 rev. 10/2020
PERMIT # ________________
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
FEE: $75.00
RECEIPT # ________________
Name of Applicant:___________________________________________________________________
Address of Applicant: _________________________________________________________________
Phone #:________________ Date of Birth: ______________ Age: ___________________
Height: ________________ Weight: __________________ Hair Color: _______________
Eye Color: ______________ Citizen of USA? Yes No
Resident of Town of Brookhaven? Yes No (If yes, see proof of residency requirements)
NYS DEC Permit #: __________________ Date of Expiration: _____________________
Make & Model of Boat: ______________________________ Registration #: ____________________
Signature of Parent or Guardian (if under 18): _______________________________________________
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. I do hereby apply for permission
from the Trustees of the Freeholders and Commonalty of the Town of Brookhaven to take shellfish.
SIGNATURE_____________________________________ DATE & TIME: ___________________
SOCIAL SECURITY #_________________________
1. Two full-faced photos taken within 30 days (11/2 x 11/2)
2. To adequately prove current residency in the Town of Brookhaven, the applicant must submit two
or more of the following: (proofs must have been issued within the last 3 months}
a. NYS Driver License, NYS Motor Vehicle Registration or NYS Non-Driver’s Identification
Card
b. Bank Statement
c. W-2 Income Tax Form
d. Utility Bill
e. Property Tax Bill
f. Major Credit Card Statement
3. Valid New York State Shellfish Digger Permit (Front and Back)
4. Fee: $75.00 in the form of check or money order payable to “Donna Lent, Brookhaven Town Clerk”
