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CARNIVAL PERMIT APPLICANT CHECKLIST • Completed Application • Fees Permit Fee of $25.00 Fingerprinting Fee of $59.00 (each applicant) • Driver’s License (copy for each applicant) • City of Modesto Business License (copy) • ‘Release and Waiver’ letter signed by each principal in presence of police witness • ‘Municipal Code Acknowledgement’ Letter signed by each principal in the presence of police witness The application process for acquiring a carnival permit requires the following documentation: ---PAGE BREAK--- MODESTO POLICE DEPARTMENT CARNIVAL PERMIT APPLICATION FEE PAID: RD BEAT MPD CASE APPLICANT INFORMATION APPLICANT NAME: List all names APPLICANT is known APPLICANT ADDRESS: APPLICANT PHONE NUMBER APPLICANT DATE OF LICENSE BUSINESS BUSINESS Last First Middle Number/Street City State Zip Code DATE: I declare under penalty of perjury that all statements in the application are true and correct. And furth, that any flase statements or ommissions may be cause for rejection of this application, or revocation of any license or permit issued. I further declare that I meet all the requirements for the permit or license I have applied for, and will abide by all rules and regulations governing said permit or license. Applicant Signature: MODESTO POLICE DEPARTMENT APPROVAL Administrative Services Supervisor Date Issuing Officer: IBM#: ARRESTS/CONVICTIONS: Date Charge City/State Disposition CORPORATION/PARTNERSHIP - LIST ALL OFFICERS NAMES, ADDRESS, PHONE ON SEPERATE SHEET. THE INFORMATION SHOULD BE ON THE CORPORATION/PARTNERSHIP LETTERHEAD. If the applicant is a partnership/corporation, the following information shall be provided for each partner/director/officer/general manager: All felonies/misdemeanors (including traffic violations and excluding parking violations) for which the applicant has been convicted within the five year immediately preceeding the date of application. Location of MANAGER NAME: List all names MANAGER is known MANAGER ADDRESS: MANAGER PHONE NUMBER (DAY): MANAGER DATE OF LICENSE Number/Street City State Zip Code List any ARRESTS/CONVICTIONS: Date Charge City/State Disposition Number/Street City State Zip Code Last First Middle Date/Time of ---PAGE BREAK--- RELEASE AND WAIVER To Whom It May Concern: I hereby authorize any Police Officer or other authorized representative of the Modesto Police Department bearing this release (or a copy of it) to obtain any information in your files pertaining to my arrest or criminal records. Consent is granted for the Modesto Police Department to furnish the information described above to its parties in the course of fulfilling its official responsibilities. I further understand that I waive any right or opportunity to read or review any background investigation report prepared by the Modesto Police Department, and I further understand that these reports are confidential. I hereby release you, as the custodian of such records, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, associates or assigns because of compliance with this authorization and request to release information, or any attempt to comply with it. Should there be any question as to the validity of this release, you may contact me. A photocopy of this release is to be considered as valid as an original. SECURITY SIGNED: DATE: (Modesto Police Department) Police Department: 601 11th Street, P.O. Box 3313, Modesto, CA 95353 (209) 572-9500 FAX (209) 572-9656 [TDD (209) 526-9211 Hearing and Speech Impaired only] ---PAGE BREAK--- CARNIVAL APPLICANTS MUNICIPAL CODE ACKNOWLEDGEMENT I/WE, THE UNDERSIGNED, MAKE THE FOLLOWING DECLARATIONS: 1. I/We have been provided a copy of the Modesto Municipal Code Sections 4-1.300 through 4-1.315. 2. I/We have read and understand the aforementioned Municipal Code Sections. 3. I/We agree that, should a massage related license be issued, that I/WE will abide by the conditions and provisions of said sections. Witness: