Office of the City Clerk
433 River St, Suite 5001
Troy, NY 12180
Phone: 518-279-7134
Fax: 518-270-4639
cityclerk@troyny.gov
Special Event Coordinator Peddler* Games of Chance/Bingo
One-Day Event Vendor Vendor*
*Fingerprinting is required every time you apply for a Vendor or Peddler permit. Contact L1 Enrollment
Services at 877-472-6915 or www.L1enrollment.com and use ORI#NY0410201. There is a charge for
this service; make payment directly to L1.
Full Legal Name:
Address:
Date of Birth:
Social Security #:
List any and all other names you have ever used:
List all nicknames you have ever used:
List in reverse chronological order all of the places you have resided in the past ten years:
Street # and Name
City or Town
State/Provi
nce
Country
Have you ever been convicted of a crime? If yes, explain:
I hereby give the City of Troy and its agents permission to conduct a criminal background check regarding my
past history. This background check includes, but is not limited to, a records check to determine whether I have
ever been convicted of any crime or have a criminal record. Giving false statements on this application will result
in immediate disqualification for the permit or license for which I have applied. I declare under penalty of perjury
that the statements made herein are true and correct to the best of my knowledge, information, and belief.
Signature:
BACKGROUND CHECK
AUTHORIZATION
Fingerprint review: Approved Denied
Local review: Approved Denied
Signature Date
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