INCORPORATED VILLAGE OF EAST ROCKAWAY 376 ATLANTIC AVENUE PO

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Application for: Tow Truck License-Chapter 269

Incorporated Village of East Rockaway

376 Atlantic Avenue, P.O. Box 189

East Rockaway, New York 11518-0189


Application for: Tow Truck License-Chapter 269


Date Issued: ________________________ License #: ___________________________

Expiration Date: _____________________ Fee: $175.00 per truck

CINCORPORATED VILLAGE OF EAST ROCKAWAY 376 ATLANTIC AVENUE PO ompensation Liability: __________________________________________________________


Note: All information contained herein will be investigated and verified, any false statement will be cause for refusal and revocation of this license. It is further understood that applicant will conform and adhere to all laws applicable and such rules and regulations as may be promulgated by the Incorporated Village of East Rockaway regulating to the use to which this license in applicable.

INCORPORATED VILLAGE OF EAST ROCKAWAY 376 ATLANTIC AVENUE PO

Attach Schedule of Towing Charges


Name of Applicant: ______________________________________ Phone # ________________

Address: _______________________________________________ Zip Code: ______________

Name of Business: _______________________________________ Phone # _______________

Address: _______________________________________________ Zip Code: ______________

Exact Location of Garage or Dispatcher’s Office: _____________________________________

Business Hours __________________________________________ Phone # _______________

Length of Time in Business _______________________________________________________


Describe below Each Vehicle for Which Application is made:

Year

Make

Model

NYS License Plate

For Official Use only




















































Application for: Tow Truck License-Chapter 269


Name of Corporation: ____________________________________ Phone #________________

Address: ______________________________________________________________________


Officers:

Name: __________________________________________ Title: ________________________

Phone # __________________________

Address: ________________________________________________ Zip Code _____________


Name: __________________________________________ Title: ________________________

Phone # __________________________

Address: ________________________________________________ Zip Code _____________


Name: __________________________________________ Title: ________________________

Phone # __________________________

Address: ________________________________________________ Zip Code _____________


Name: __________________________________________ Title: ________________________

Phone # __________________________

Address: ________________________________________________ Zip Code _____________

INCORPORATED VILLAGE OF EAST ROCKAWAY 376 ATLANTIC AVENUE PO

Have any of the Officers ever been arrested or been summoned to Court?

 YES No If Yes, please give particulars: _____________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Application for: Tow Truck License-Chapter 269


State of New York}

County of Nassau} ss:


______________________________________________being duly sworn deposes and says that the individual making the foregoing application: that the answers to the foregoing questions and all other statements contained herein are true.


Sworn to before me this ____day of

________________________, 20_____

________________________________ ____________________________________

Notary Public Applicant’s Signature



J:CLERKS OFFICE\Misc. Licenses\Tow Truck


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