PLEASE PRINT

LAST NAME: ______________________________ FIRST NAME ____________________ TEL.: _______________

ADDRESS:  _____________________________________________________________________________________

MAILING ADDRESS (if different than above): _________________________________________________________

VEHICLE DESCRIPTION:   YEAR _________ MAKE __________________________ MODEL _______________

VEHICLE LIC PLATE # (required) _________________________________________________ STATE ________

PERMIT FEE: $25.00             SECOND/LOST PERMIT $5.00             RESIDENT 65 OR OLDER   NO CHARGE

Mail To: Town of Gardiner                                                                                    Make Checks Payable to:

                PO Box 1                                                                                                                      Town of Gardiner

                Gardiner, NY 12525

* ENCLOSE A STAMPED SELF ADDRESSED                              AMOUNT ENCLOSED: $_______

   ENVELOPE IF TO BE RETURNED BY MAIL

Received by: _______                               Date: ___________                         Permit #: ________