Fillable Donna Lent, Town Clerk (Town of Brookhaven)

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Donna Lent, Town Clerk (Town of Brookhaven)

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U.S.A. forms for Town of Brookhaven

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Peddling Permit Application
TC-19 rev. 11/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 1 of 3
TO BE FILLED OUT BY PEDDLER (PERSON SELLING) - FEE: $150.00
(CONTINUED NEXT PAGE)
1. WAR VETERAN?
Yes No
2. IF YES, STATE LICENSE NUMBER:
3. NAME: FIRST LAST MAIDEN NAME (IF APPLICABLE) 4. TELEPHONE NUMBER:
5. STREET ADDRESS: TOWN: STATE: ZIP:
6. DATE OF BIRTH: 7. PLACE OF BIRTH: 8. HEIGHT: 9. WEIGHT:
10. SOCIAL SECURITY NUMBER: 11. COLOR OF EYES: 12. COLOR OF HAIR:
13. APPLICANT’S PLACE OF RESIDENCE FOR PAST 5 YEARS: (USE ADDITIONAL SHEET IF NECESSARY)
14. APPLICANT’S BUSINESS OR EMPLOYER FOR PAST 5 YEARS: (USE ADDITIONAL SHEET IF NECESSARY)
15. HAVE YOU EVER BEEN
CONVICTED OF A FELONY?
Yes No
16. IF YES, DATE: 17. IF NOT APPLYING FOR VEHICLE PERMIT, WHAT ITEMS ARE YOU SELLING?
18. WHO OWNS THE VEHICLE? 19. CURRENT VEHICLE PERMIT NUMBER:
20. Items listed below must be submitted with application:
1. Valid NYS driver’s license
2. NYS Sales Tax Certificat
e (if applicable)
3. One full-faced photo taken within 30 days, measuring 11⁄2” by 11⁄2”
4. Suffolk County Food Manager’s Certificate (If applicable)
5. Insurance certificate showing $500,000 in Commercial General Liability Insurance, naming
the
Town of Brookhaven as an additional insured **All Insurance Certificates must be in Business Name**
21. SIGNATURE: 22. DATE:
For Office Use Only
Permit #P: #M: Date:
Receipt#: Transaction ID #:
DCJS History: SOR Confirmation:
Peddling Permit Application
TC-19 rev. 11/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 2 of 3
AUTHORIZATION FOR RELEASE OF INFORMATION
I, the undersigned, hereby authorize the release to the Town of Brookhaven Department of Public Safety,
any and all records that relate to my background, including but not limited to records and reports of
military service, local/state and federal law enforcement agencies, local/state and federal tax bureaus,
credit bureaus, hospitals and institutions and psychological histories. I voluntarily authorize the Town of
Brookhaven to make inquiry into my past criminal convictions in any state or federal court.
I authorize the release of results/findings of any polygraph examinations I have taken.
I authorize an inquiry be made of my past employer(s).
I authorize an inquiry be made of my present employer(s).
(Make note if you do not want your present employer contacted and why.)
I acknowledge by this authorization that I release any and all persons/institutions and legal entities from
any and all obligation of liability arising from the release of records described herein to the parties herein.
NOTE: A copy of this authorization shall be considered effective and valid as the original.
STATE OF NEW YORK
COUNTY OF SUFFOLK
On this _____ day of ______________, 20____ before me personally came to me __________________
_____________ known to be the individual described in and who executed the foregoing instrument and
acknowledged that he executed the same.
___________________________
Notary Public
__________________________________________
Social Security Number
___________________________
Date of Birth
_________________________________________________________
Print Name
_______________________________________
Street Address
________________________________________
City/Village/Town/State
______________________
Zip
____________________________________________________________________________________
Signature
_____________
___________________
Date
Peddling Permit Application
TC-19 rev.11/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 3 of 3
TO BE FILLED OUT BY OWNER OF VEHICLE - FEE: $200.00
23. WAR VETERAN?
Yes No
24. IF YES, STATE LICENSE NUMBER:
25. NAME: FIRST LAST 26. TELEPHONE NUMBER:
26. STREET ADDRESS: TOWN: STATE: ZIP:
28. DATE OF BIRTH: 29. PLACE OF BIRTH: 30. HEIGHT: 31. WEIGHT:
32. SOCIAL SECURITY NUMBER: 33. COLOR OF EYES: 34. COLOR OF HAIR:
35. APPLICANT’S PLACE OF RESIDENCE FOR PAST 5 YEARS: (USE ADDITIONAL SHEET IF NECESSARY)
36. APPLICANT’S BUSINESS OR EMPLOYER FOR PAST 5 YEARS: (USE ADDITIONAL SHEET IF NECESSARY)
37. TYPE OF VEHICLE: 38. LICENSE PLATE NUMBER: 39. NAME ON VEHICLE:
40. BUSINESS OR TRADE FOR WHICH LICENSE IS REQUESTED (ITEM SOLD): 41. HEALTH CERTIFICATE NUMBER (IF APPLICABLE):
42. HAVE YOU EVER BEEN CONVICTED OF A FELONY?
Yes No
43. IF YES, DATE:
44. ITEMS LISTED BELOW MUST BE SUBMITTED WITH APPLICATION:̀
1. Valid NYS Vehicle Registration NOT Valid NYS Driver’s License
2. Suffolk County Health Certification (if applicable)
3. NYS Sales Tax Certificate (if applicable)
4. Insurance certificate showing $250,000/500,000 for bodily injury coverage on a split limit policy or
$500,000 on a combined single limit policy on vehicle, showing the Town of Brookhaven as certificate
holder (Vehicle VIN number or identification number must be on certificate)
5. Insurance certificate showing $500,000 in Commercial General Liability Insurance, naming the
Town of Brookhaven as an additional insured **All Insurance Certificates must be in Business Name**
45. SIGNATURE: 46. DATE:
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Donna Lent, Town Clerk (Town of Brookhaven)

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Completed 12 February 2021

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