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CIRCUS/CARNIVAL LICENSE APPLICATION

  1. MM-DD-YYYY

  2. Street #, Street Name, City, State, Zip Code

  3. (Area Code)XXX-XXXX

  4. Description:__________________________________________________________________________
    ____________________________________________________________________________________
    ____________________________________________________________________________________

    Date(s):_____________________________________________________________________________

    Location:____________________________________________________________________________

  5. Number of Animals:____________

    Rides:_______________________

    Games:______________________

    You may be subject to Approvals/Licenses/Inspections by New York State, as well as Clinton County Health Department. For animals, current health and inoculation certificates must be available.


  6. Furnish on ACORD form 25 or comparable
    City of Plattsburgh named as additional insured
    Thirty (30) day written cancellation notice
    General Liability - Premises/Operations
    BI/PD $1,000,000 CSL/$2,000,000 Aggregate
    Worker's Compensation and Disability


  7. Carnival $120.00/day

    Circus $375.00/day


  8. __________________________________________________________________________________
    Applicant Signature

  9. Name

  10. Street #, Street Name, City, State, Zip

  11. (Area Code) XXX-XXXX

  12. Insurance: (Y) (N) _________________


    Police: (Y) (N):____________________
    (Initial/Date)

    Clerk (Y) (N)______________________

  13. Leave This Blank: