-30 TRANSPORTATION PERMITS … TRUCKING … FLEET … COMPANY FLEET 1) Indicate type of permit you are applying for______________________________________________. 2) Applicant ___________________________________________________________________________. 3) Address including Street:______________________________________ , County: _______________ City, Town or Village: __________________________ and Zip Code:_________________________. 4) Between what streets (if outside city limit and not known by bldg. #, specify location in relations to nearest road/highway) ________________________________________________________________. 5) When filing for individual trucking permits (not a Fleet Permit) please complete the following, using additional sheets if necessary: Make of Truck: Year: Type: VIN #: 6) Has the applicant or (if partnership) any of the partners, or (if a corporation) any of he officers, directors, or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind except traffic violations? Yes ( ) 7) No ( ) Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders any interest, directly or indirectly, in any premises or business where any alcoholic beverage is manufactured or sold at wholesale or retail, whether by stock ownership, interlocking directors, mortgage or lein on, or ownership of any real or personal property, or by any other means including loans? Yes ( )No ( ) If yes, set forth the location any type of such business, the nature of the interest and the date when it was acquired. 8a) If a corporation, under what law were you incorporated? _____________________________________. Date of corporation?__________________________________________________________________. 8b) If a foreign corporation, please state whether you are registered to do business in New York: Yes ( ) No ( ) If yes, date registered: _______________________________ American LegalNet, Inc. www.FormsWorkFlow.com * State whether applicant owns the vehicles included in this application. _________________ If not, state name and address of the owner of each said vehicle and the terms under which the applicant operates the same.__________________________________________________________ __________________________________________________________________________________ 8c) State names and addresses of all officers and director of said corporation as of application date: NAME RESIDENCE CITIZENSHIP TITLE AGE 8d) The names and addresses of the owners of stock as of the date of filing application are as follows: (If there are more than 10 stockholders, set forth those holding 10% or more of issued stock.) Add schedule if more space is needed. NAME ADDRESS CITIZENSHIP SHARES Common WHEN ACQUIRED Preferred THE FOLLOWING TO BE FILLED OUT ONLY BY INDIVIDUAL OR PARTNERSHIP APPLICANTS 9) NAME OF APPLICANT (If partnership, name each partner) RESIDENCE CITIZENSHIP AGE American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF PARTNERSHIP The undersigned, each for himself, certifies that he is the applicant above named; that he knows the contents of the above application and the statements contained therein and the same are true of his own knowledge. The undersigned certifies that he/she has read the conditions for the permit applied for and agrees to comply with these conditions. _____________________________________ ____________________________________ _____________________________________ ____________________________________ _____________________________________ _____________________________________ (Signature of applicant or of each partner) (Residence) (Home Phone) ____________________________________ (Dated) THIS CERTIFICATION TO BE SIGNED AND DATED BY A CORPORATION _____________________________________ certifies that he is ________________________ (Title) of the above named applicant corporation; that he knows the contents of the above application and the statements and answers therein; that the same are true of his own knowledge; that he has been authorized, by order of the Board of Directors of said applicant corporation to make the statements and answers in this application in behalf of said corporation with the same force and effect as if said corporation made such statements and answers itself. The undersigned certifies that he/she has read the conditions for the permit applied for and agrees to comply with these conditions. __________________________________________ (Signature of authorized Officer) ____________________________________ (Street Address) ____________________________________ (City, Town or Village) ____________________________________ (Zip Code) (Telephone #) ____________________________________ (Dated) ____________________________________ (1-800-Phone Number) American LegalNet, Inc. www.FormsWorkFlow.com