Certification Application For Collection & Community Service Programs Form 2010
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Certification Application
DROPOFF OR COLLECTION & COMMUNITY SERVICE PROGRAMS
Mail to: CalRecycle • Division of Recycling • Certification Section
801 K Street • MS 15-59 • Sacramento, CA 95814-3533
Questions? Call: (916)324-8598
Office Use Only
Instructions
• Print In Ink Or Type.
App. # _____________________________________________________
Category: ❏ Dropoff or Collection Program ❏ Community Service Program
• Submit A Separate Form For Each
Location Or Category.
❏ Neighborhood Dropoff Program
• Indicate N/A For Any Items Which
Are Not Applicable.
Certification No. _____________________________________________
❏ 2 year
❏ Probationary: Expiration _______________________
OPERATOR INFORMATION
1)
Contact Person _________________________
________________________________
_________________________________________
_______________________
First
Middle
Last
Title
Organization Name ________________________________________________________
____________________________________________________________
Fictitious Business Name, If applicable
Business Address ___________________________________
_________________________
___________________________
_
__________
_______________
Address
City
County
State
Zip Code
Mailing Address ____________________________________
_________________________
___________________________
___________
________________
Address
City
County
State
Zip Code
(
)
(
)
Telephone Number ____________________________
___________________
___________________________________
____________________________________
Fax
Type Of Organization
2)
(Check one box)
❏
a.
Individual:
❏
General or
Limited Submit copy of current partnership agreement.
b.
Partnership:
❏
c.
Corporation: Submit Articles of Incorporation and list of current corporate officers.
Corporate # as filed with Secretary of State __________________________________________________________________
Profit
or
Nonprofit (Select one)
Domestic or
Foreign (Select one) If foreign, submit copy of certificate from California Secretary of State.
Agent for service of process
❏
Limited Liability Company: Submit Articles of Organization, Statement of Information and operating agreement.
d.
Foreign (Select one) If foreign, submit copy of certificate from California Secretary of State.
Domestic or
Agent for service of process ___________________________________________________________________________
___
❏
e.
Husband and Wife Co-Ownership: Name of Spouse ________________________________________________________________________
❏
f.
Nonprofit Organization with State of California or Federal Tax Exempt Status.
❏
g.
Government or Public Agency: ________ City ________ County _______ City & County ______ School ________ State _________ Federal
Submit governing board resolution authorizing this application.
❏
h.
Other (Explain): ___________________________________________________________________________________________________
3) Submit a copy of the fictitious business name statement, if applicable
4) Federal ID # (Employer ID#) _______________________________________________________________________________________________
Corporations, partnerships and other organizations with paid employees must provide a Federal ID#.
Printed on recycled paper
DOR 6/93 7
Rev. 2/10
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