Shellfish Shipper A - Commercial Fishing Permits Center

Vessel Name

Vessel Use / Endorsement

Pleasure
Commercial

Official Number

Confirm Official Number

Contact Information

Name

First Last

Email*

Enter Email Confirm Email

Phone*

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Address (If different)

Street Address City State / Province / Region ZIP / Postal Code Country

Other Address for Business or Facility Location

Street Address City State / Province / Region ZIP / Postal Code Country

Corporation?

Yes
No

For Corporate Applicants, Are you a Corporation in Good Standing?

Yes
No

Country Issuing Taxpayer Id:

NYS Domicile?

Yes
No

Township	County	Taxpayer ID/SSN

Home Phone

Business Phone

Fax Phone

Physical Description (N/A if Corporation)

Date of Birth

Gender

Male
Female

Hair Color

Eye Color

Height

Weight

Permit Type: Shellfish Shipper -A

Permit Fee$300.

Company Name

Contact Information for Authorized Representative

Name

First Last

Business Phone

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Information for Corporate Officer

Name

First Last

Business Phone

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Information for Partner

Name

First Last

Business Phone

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Information for Sole Owner

Name

First Last

Business Phone

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Condition Number 16 Applies to ALL Shellfish Dealers who hold a Class A. 8 or D Permit:

In addition to the information that must be included on a shellfish dealer tag, the following statement must appear in BOLD CAPITAL TYPE following the type and quantity of shellstock: "THIS TAG IS REQUIRED TO BE ATTACHED UNTIL CONTAINER IS EMPTY OR IS RETAGGED AND THEREAFTER KEPT ON FILE, IN CHRONOLOGICAL ORDER, FOR 90 DAYS." "RETAILERS: DATE WHEN LAST SHELLFISH FROM THIS CONTAINER SOLD OR SERVED _______ ,"

Shellfish Shipper Permit Number

Application Fee

Price:

RENEWAL ADVANCED PAYMENT OPTION

No Additional Years
2 year renewal
3 year renewal
4 year renewal
5 year renewal

Total

$0.00

Consent*

I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.

I agree

NAME:*

Type your full name to sign this secure webform

Signature*

CAPACITY OF PERSON SIGNING (E.G., OWNER, AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)

Date

Authorization*

I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected permits. I understand that my application will be processed in the order in which it is received by Commercial Fishing Permits Center, a private fee-for-service documentation company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Commercial Fishing Permits Center's no refund policy. I understand that submitting another application for a license or permit will supersede the current/pending application for that license or permit. I understand that Commercial Fishing Permits Center does not issue or sell any licenses or permits.

I agree

Credit Card

Card Details

Cardholder Name

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BILLING ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

By clicking submit you agree to these Terms and Conditions and the above authorization of payment.