Please read all instructions and then complete the following information and
Print, Sign, Notarize, Date and Mail to:

Incorporated Village of Farmingdale
PO Box 220   361 Main Street
Farmingdale, NY 11735
(516) 249-0093
www.FarmingdaleVillage.org

APPLICATION FOR PEDDLER'S LICENSE

APPROVED
Board of Trustees


_________________________________________


Date
_______________________

 

Permit #:

Date:

Fee:

Receipt #:


We hereby apply for a license to (describe operation):
Name: (if corporation or partnership, please complete separate questionnaires)
Home Address: Home Phone:
Business Address: Business Phone:
How long at this address? Date of Birth: Age:
Height: Weight: Color of eyes:
Have you any mental or physical infirmity?

Have you even been convicted of any crime including moving traffic offenses? Please explain.

Number of employees (complete personal information sheet for each employee):

What do you sell?

Where will you operate?

If you use a vehicle:
Make and Year: Model Number: NY Registration:
Weight: Type: Is vehicle in good mechanical condition?
Name and address of manufacturers represented:

  1.  


  2.  
Are you licensed by any other governmental agencies? If so, please provide agency name and license numbers:


I affirm that the above statements are true. I further agree to conform to all rules and regulations set by the Board of Trustees in connection with the issuance of the subject license and that failure to do so will constitute grounds for voiding of my license.



_________________________________________
Signature of Applicant



Date:_________________________________________
State of New York
Village of Farmingdale


__________________________________________________________ be duly sworn deposes and says that he/she is the individual making the application for a Peddler's License; that the answers to the foregoing questions and other statements contained therein are true in my knowledge.



_________________________________________
Notary Public