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HAULER'S APPLICATION (TRASH REMOVAL)

  1. IF APPLICATION IS MADE ON BEHALF OF A CORPORATION, SUCH INFORMATION SHOULD BE FURNISHED AND THE OTHER INFORMATION SHALL REFER TO THE OPERATING MANAGER OF THE BUSINESS.

  2. APPLICATION FOR LICENSE TO COLLECT AND REMOVE AND/OR DISPOSE OF REFUSE IN THE CITY OF PLATTSBURGH IN ACCORDANCE WITH SECTION 183 OF THE CODE OF THE CITY OF PLATTSBURGH.

  3. MM-DD-YYYY

  4. SEX

  5. HAVE YOU EVER BEEN CONVICTED OF A CRIME:

  6. MM-DD-YY

  7. City, State

  8. DO YOU HOLD A VALID N.Y.S. LICENSE AS PER SECTION 501 OF THE VEHICLE AND TRAFFIC LAWS OF THE STATE OF NEW YORK:

  9. HAS IT BEEN SUSPENDED OR REVOKED?

  10. IS THIS VEHICLE PROPERLY IDENTIFIED AS PER CODE:

  11. CERTIFICATE OF INSURANCE PROVIDED: NAMING CITY OF PLATTSBURGH AS ADDITIONAL INSURED. PUBLIC LIABILITY IN THE AMOUNT OF $1,000,000.00 FOR DAMAGES TO PROPERTY FROM ANY ONE ACCIDENT OF INCIDENT (COMBINED SINGLE LIMIT FOR PERSONAL INJURY OR DEATH OR PROPERTY DAMAGE) $2,000,000.00 AGGREGATE:

  12. Signature of Applicant

  13. City Clerk

  14. Name

  15. MM-DD-YYYY

  16. Leave This Blank: