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Office of the City Clerk City Hall - Room 202 Albany, NY 12207 Phone (518) 434-5090 Fax (518) 434-5081 Kathy M. Sheehan Danielle Gillespie Mayor City Clerk APPLICATION FOR A HANDBILL LICENSE Fee Paid: Name of Applicant: Home Address: City: State: Zip Business Address: City: State: Zip Home Phone: Business Phone: Date of Birth: Place of Birth: Social Security Number: Weight: Height: Color of Eyes: Color of Hair: Do you intend to distribute handbills in public places in the City of Albany, from door to door or both? Are you a self-employed vendor? Yes No If not self-employed by whom are you employed? If self-employed or in a partnership, provide the name of Do you have credentials authorizing you to act as a representative or employee of ---PAGE BREAK--- If so enter the nature and extent of the authority and the name of the authority and the name and address of the person or corporation giving the credentials. (Credentials to be exhibited to the City Clerk) Has a Handbill license issued to you, ever been revoked or denied, in this City or elsewhere in the past five years? Yes No If so, state when & where: Have you ever been arrested or convicted of any crime or misdemeanor? Yes No If so, state when & where and the nature of Crime: State what type of handbill you will be State the period of time you wish to distribute handbills: One week or less $25 One week to three months $50 3mos to 6mos. $75 6 mos. to 9 mos. $115 9 mos. to a year $150 State the punishment or penalty if pending or undisposed: Are you currently or have you ever been on parole or probation? Yes No If you have been on parole or probation state when, where and by what agency: one) Federal State County Have you ever been known by any other name other than the one given on this application? Yes No If yes, please provide the ---PAGE BREAK--- State of New York City and Count of Albany duly sworn, deposes and says that he/she is the person signing the forgoing application for a vender’s license and that the answers given to the questions above are true in all respects and particulars and are made for the purpose of obtaining the issuance of said license. Signature of Applicant Sworn before me this Day of 20 Date of Application Commissioner of deed or Notary Public Application (approved) (denied) and license (issued) (not issued) License no. Rev. 5/2019