Please
read all instructions and then complete the following
information and mail to:
Incorporated
Village of Farmingdale
PO Box 220 361 Main Street
Farmingdale, NY 11735
(516) 249-0093
www.FarmingdaleVillage.org
Village of
Farmingdale LANDSCAPER LICENSE-APPLICATION
Valid for the Calendar Year Issued
New
Application
Fee
Paid
Renewal
Receipt
No.#
Fees: New $100.00 Renewal $75.00 Vehicle
Fee $10.00 per truck/trailer
Name of Company
Address
Name of
Applicant
Address
Is the applicant, or if
a co-partnership or corporation, are the partners or
officers therein citizens of the United States?
Does Entity intend on
using pesticides? (If yes, a valid D.E.C. Certificate must
be attached to application)
How many vehicles are
presently owned and operated?
How many vehicles,
owned by others, are operated by the applicant?
Locations the vehicles
will be stored:
Has the applicant, or
any partner or officer of the applicant ever been
convicted of any felonies or misdemeanors?
If yes,
List and Explain:
For
Corporations: State of Incorporation: ____________
Date of Incorporation: ____________
Name
Address
Date of Birth
President
Vice President
Secretary
Treasurer
For
Partnerships: List names and addresses of owners:
Name
Address
Date of Birth
For
Individual Proprietorships: List name and address of
owner.
Name
Address
Date of Birth
VEHICLES TO BE LICENSED
Year and Make
Vehicle ID Number
License Plate Number
Insurance Company Code
For Court Use Only
In consideration of the
granting of the License hereby applied for, the applicant
agrees that service is made by the Village of Farmingdale
or any Department, thereof, upon the person to whom such
license is issued by leaving a copy of any such Paper,
Notice, Letter, Summons, Complaint, or Legal Process at
the address herewith given and it is further agreed by the
Applicants that they will conform with all rules and
regulations of the Village of Farmingdale governing
Landscapers.
STATE OF NEW YORK
COUNTY OF NASSAU
I,
(Title)
Of
(Name of Company),
described in the foregoing
application, and that he/she makes the said application
on behalf of the Company/Corporation/Entity; that the
answers to the questions and other statements contained
herein is true of his/her own knowledge and belief, and
that he/she signed the foregoing application, for, and
on behalf of the said Company/Corporation/Entity.
Sworn to before me
this
day of
20
Signature of applicant:
Notary Public:
FOR OFFICE USE ONLY
Police Departments Record
Check:_______________________________________________________
Insurance Certificate attached and
appropriate:___________________________
D.E.C. Certificate attached:
Yes___________ not applicable_____________
At the Board of Trustees meeting held on
_________________, the application was
Approved:____________Disapproved:____________
Approved with
stipulations:______________________________________________________________________________________
License number
issued:_______________________ on
_________________________________.