Waste Hauler Permit Application For Collection And Transportation Of Solid Waste And Recyclable Materials In Putnam County Page 15
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15Waste Hauler Permit Application for Collection and Transportation of
Solid Waste and Recyclable Materials in Putnam County
SECTION 14 – NOTARIZED CERTIFICATION
Notarized Certificate of Applicant
This certification must be completed and executed, individually, by the person completing the
application on behalf of the Applicant and shall be notarized.
State of New York
County of Putnam
I, __________________________________, being duly sworn, state that I am the__________________
(Name of person executing application)
(Title)
__________________________ of __________________________________________ and that I have
(Title)
(Applicant or Business)
been duly authorized to complete and execute this application on behalf of _______________________.
(Applicant)
I, ___________________________________, hereby certify that I have read and understand the
(Name of person executing application)
instructions and the questions set forth in this application; and
that to the best of my knowledge the information provided in response to the questions set forth herein is
full, complete and truthful, and has been prepared based upon my personal knowledge, as well as
diligent search of all business and other records in my possession and control; and
that I understand the that Putnam County Department of Health my, by any legal means it deems
necessary and appropriate, determine the accuracy and truth of the statements made in this applications;
and
that I understand that the Putnam County Department of Health shall rely upon and issue a
determination as to ___________________________________’s permit status based upon the
(Applicant)
information provided herein, along with any further information provided during the verification
process.
___________________________________
(Signature)
(Title)
___________________________________
(Print or Type Name)
Sworn to before me this _________day
of ______________________, 20_____
________________________________
(Notary Public)
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