| 1. |
Applicant: ____________
|
( ) Natural person(s) |
|
( ) Corporation |
|
( ) Partnership |
|
( ) Other _____
(Specify) |
|
| 2. |
Business address: _____ |
|
_____ |
|
| 3. |
If applicant is a corporation: |
|
State of incorporation _____ |
|
Officers: |
President _____ |
|
Vice President _____ |
|
Secretary _____ |
|
Treasurer _____ |
|
Directors: _____ |
|
_____ |
|
_____ |
|
|
Shareholders (and percent interest of each shareholder): |
|
_____ |
|
_____ |
|
_____ |
|
|
If applicant is a Rhode Island Corporation, attach a certificate of good standing
from the Rhode Island Secretary of State. If applicant is a foreign corporation, attach
a certificate of good standing from the state of incorporation and a certificate of
authority to transact business in Rhode Island from Rhode Island Secretary of State.
|
|
| 4. |
If applicant is a partnership, list all general and limited partners: _____ |
|
_____ |
|
| 5. |
Operating location: _____ |
|
If applicant has entered into a lease for the property from which mopeds, tripeds,
and scooters are to be rented, attach a copy of the lease agreement.
|
|
(Note: If license is issued, it will be issued for this location only.) |
|
| 6. |
Insurance coverage for operators of rented mopeds, tripeds, and scooters and insurance
coverage for any liability of the applicant/lessor for personal injury and/or property
damage by reason of the rental of the applicant's/lessor mopeds, tripeds, or scooters,
not less than ten thousand dollars ($10,000.00) coverage for property damage per accident,
twenty-five thousand dollars ($25,000) for injury or death sustained by one (1) person,
and fifty thousand dollars ($50,000) for all personal injuries or deaths resulting
from one (1) accident:
|
|
|
Name of insurance carrier _____ |
|
Property damage _____ |
|
Personal damage _____ |
|
| 7. |
Describe type of (a) mopeds, (b) tripeds and (c) motor scooters applicant intends
to rent: _____
|
|
_____ |
|
| 8. |
(a) |
|
Number of vehicles and registration numbers as issued by the State of Rhode Island
and the Vehicle Identification Number as issued by the manufacturer of each vehicle
applicant intends to rent: _____
|
|
(b) |
|
As to each such vehicle, a certificate by duly authorized state inspection facility
indicating that any such vehicle passed an annual inspection, as governed by rules
promulgated by the Rhode Island State Department of Transportation. _____
|
|
|
_____ |
|
| 9. |
Does applicant or any officer, director, shareholder or partner thereof or any entity
in which applicant is an ownership interest or if applicant is an individual, any
member of applicant's immediate family have any other license to rent mopeds tripeds,
or motor scooters in the Town of New Shoreham or have any interest, direct or indirect,
in any other such license issued or applied for?
|
|
Yes____________ If yes, give details of license: _____ |
|
_____ |
|
No____________
|
|
|
10
|
If applicant is a corporation, do any shareholders own shares of, or have any direct
or indirect interest in, an existing corporation licensee, or a corporation for which
a license has been applied for?
|
|
Yes____________ If yes, name existing license: _____ |
|
_____ |
|
No____________
|
|
| 11. |
If applicant is a corporation, is any officer or director thereof, an officer or director
of an existing licensee?
|
|
Yes____________ If yes, name existing license and office or directorship held. _____ |
|
_____ |
|
No____________
|
|
| 12. |
Has applicant been convicted of any felony or misdemeanor within the past five (5)
years?
|
|
Yes____________ If yes, specify: _____ |
|
_____ |
|
No____________
|
|
| 13. |
Has applicant been found to have violated any motor vehicle law or code within the
past five (5) years?
|
|
Yes____________ If yes, specify: _____ |
|
_____ |
|
No____________
|
|
| 14. |
Has applicant been found to be in violation of any ordinances of New Shoreham within
the past five (5) years?
|
|
Yes____________ If yes, specify: _____ |
|
_____ |
|
No____________
|
|
| 15. |
Does applicant give the Town Council permission to contact state municipal authorities
and applicant's insurance agent, broker, or carrier to obtain information relating
to this application? Yes____________ No____________
|
|
| 16. |
If applicant has been issued a license by the State of Rhode Island or the Town Council
hereunder to rent motorized bicycles, motorized tricycles or motor scooters the previous
year, attach a copy of applicant's financial statements. If applicant has been previously
issued a license by the State of Rhode Island or by the Town Council hereunder, attach
a copy of the license. If applicant has not previously been issued a license, attach
a copy of applicant's pro forma financial statements.
|
|
| 17. |
Is this an |
( ) original application? |
|
( ) renewal application? |
