HomeMy WebLinkAbout(0020) Rhino Removal GOP Application May 2021.pdfFoRTWORTH. APPLICATION FOR
NON-EXCLUSIVE PRIVILEGE AGREEMENT
(Collection and Transportation of IVlunici I S pa 1"d W st
o � a e)
INSTRUCTIONS: Complete form and return to City of Fort Worth, Code Compliance Department, Solid
Waste Services Division, 4100 Columbus Trail, Fort Worth. Tx 76133
Trade Name of Applica
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Physical teal Address Fort
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Contact am
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Conta
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MMailing Address
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Telepphone Number
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Fax Number
1. Briefly describe the nature and character of the service the applicant proposes to
render.
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2. Estimated Number of Vehicles Operating Under this Agreement. A list
of all vehicles must be attached to this application. The list shall
include make, model, year and license plate number of all vehicles to /0
operate under this Agreement.
3. Do each of the vehicles listed in question 2 above have a current City
of Fort Worth Haulinq Permit? I PO
4. Applicant has attached Certificated of Liability Insurance as required in Circle One
the Non -Exclusive Privilege Agreement, Section 13 <fo NO
5. Signature of the perso on the Company to sign this Agreement.
Signature o .w�r,•+�,,,l��trrir r►y Pas aC
Title F' lew Vim„ Date = y
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For City Use Only
Privilege Agreement Number: Date Approved:
Period Covered: to Approved M&C Number:
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Distribution: City Secretary, Solid Waste Services Division, Applicant