Application For Curbside Registration Form Page 4
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4DECLARATION AND SIGNATURES
20) a. I agree to operate the facility in compliance with the California Beverage Container Recycling and Litter Reduction Act, including all relevant regulations contained
in Chapter 5 of Division 2 of Title 14 of the California Code of Regulations.
b.I declare under penalty of perjury under the laws of the State of California that all information on this application and supporting documents is true and
correct and that I am authorized to sign this application.
Note: Please refer to note below (*) for information on who is eligible and required to sign this form
.
Executed at ______________________________________
_____________________________________
______
on ___________________
City
County
State
(Month/ Day/Year)
Signature _________________________________________________
Title ____________________________________________________
Residence Phone (
)
Printed Name ______________________________________________
___________________________________________
Residence Address ________________________________
_____________________________________
______
_____________________
Address
City
State
Zip Code
Social Security # ** __________________________________________
California Driver License # _____________________________________
Executed at ______________________________________
_____________________________________
______
on ___________________
City
County
State
(Month/ Day/Year)
Signature _________________________________________________
Title ____________________________________________________
Residence Phone _____ )
(
Printed Name ______________________________________________
______________________________________
Residence Address ________________________________
_____________________________________
______
_____________________
Address
City
State
Zip Code
Social Security # ** __________________________________________
California Driver License # _____________________________________
Executed at ______________________________________
_____________________________________
______
on ___________________
City
County
State
(Month/ Day/Year)
Signature _________________________________________________
Title ____________________________________________________
(
)
Printed Name ______________________________________________
Residence Phone
______
_____________________________________
Residence Address ________________________________
_____________________________________
______
_____________________
Address
City
State
Zip Code
Social Security # ** __________________________________________
California Driver License # _____________________________________
Executed at ______________________________________
_____________________________________
______
on ___________________
City
County
State
(Month/ Day/Year)
Signature _________________________________________________
Title ____________________________________________________
Residence Phone (
)
Printed Name ______________________________________________
___________________________________________
Residence Address ________________________________
_____________________________________
______
_____________________
Address
City
State
Zip Code
Social Security # ** __________________________________________
California Driver License # _____________________________________
Attach Additional Sheet if Necessary
.
* Who must sign affidavit: For Individuals-the applicant; Partnerships-each partner; Husband & Wife Co-ownerships-both husband & wife; Corporations, Limited Liability
Companies, Government or Public Agencies-persons with authority to legally bind said entity to a contract (e.g., Executive Officer, Managing Member).
** Providing the Social Security Number is voluntary in accordance with the Privacy Act of 1974 (PL 93-579). This information is used for applicant identification
purposes. Authority: California Beverage Container Recycling and Litter Reduction Act (Public Resources Code Section 14500 et seq.).
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