Expeditor Registration

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EXPEDITOR ONLINE REGISTRATION

Please fill out the form below to register as an expeditor with the Town of Brookhaven on an annual basis.

The annual registration fee is $75 for the business and owner to be registered as an expeditor. If you would like to register an employee other than the owner, the registration fee will be $150 for the owner and the employee.

BUSINESS INFORMATION

Business Name*

Employer ID*

Full Business Address (Address, City, State, Zip)*

Full Mailing Address If Different (Address, City, State, Zip)

Business Type*

OWNER INFORMATION

Please Enter the Owner / Managing Partner / President / Chief Operating Officer (COO) Contact Information Below

Full Name*

Full Owner Address (Address, City, State, Zip)*

Full Mailing Address If Different (Address, City, State, Zip)

Date of Birth*

Phone Number*

###-###-####

Email Address*

A receipt will be emailed to this account.

Name, Address, Phone Number and Title of Person Designated to Accept Legal Notices*

Have you or any additional employees you are registering ever been convicted of a felony or misdemeanor in the last five (5) years?*

Yes
No

If yes, state the original charge, the charge upon conviction and the sentence imposed, the date of conviction and the court that imposed it, including the docket, index, indictment or file number in such court

Have you or any additional employees you are registering ever had a judgment against you relating to ligation involving your expediting services or other business dealings?*

Yes
No

If Yes, state the original causes of action, the result of the litigation or the nature of any settlement, the date of the decision or settlement and the court or jurisdiction that imposed it, including the docket, index or file number in such court.

By typing my name below, I, the undersigned affirm under penalties of perjury that the information contained herein is true. I further affirm that this application is accepted on the condition that the provisions and regulations of the Town of Brookhaven codes and the requirements of the respective Town departments shall be complied with. It is understood that any determination of violation as enumuerated in section 90-7 of the Town of Brookhaven, may result in the immediate revocation of this registration:*

ADDITIONAL EXPEDITOR EMPLOYEES

Would You Like to Register an Employee Also?

PAYMENT INFORMATION

Payment Type*

Credit Card
e-Check

Billing Street Address*

Billing Address Zip Code*

Credit Card*

Name on Credit Card*

Credit Card Number*

Credit Card CVV2 Verification Code*

Expiration*

I acknowledge that I will incur a convenience fee of 2.35% of my order total with a minimum fee of $1.50. I acknowledge that if I dispute the charge on my credit/debit card, my application will be null and void and I will be required to reapply with the Town.*

I acknowledge that if I dispute the charge on my credit/debit card, I will incur a $75.00 Administrative Fee.*

Subtotal:

Convenience Fee:

Total Cost:

Subtotal

Credit Card Convenience Fee

Total Cost

HID AVS

HID Transaction Type

Prove You Are a Human*