Alternative Transportation Permit Application

The following information MUST be provided to the Breese Police Department before your ATV permit can be issued:

Inspection Form - obtain at no cost from Breese Lawn & Garden
Hold Harmless & Release of Liability Form (must be signed)
Copy of Proof of Liability Insurance
Copy of Driver's License of operating parties
$35.00 cash or check payable to City of Breese

You may upload any completed forms with this application.

You may drop off all forms and payment in person at the police department between normal business hours. If after hours, please use the drop box in the lobby or outside City Hall.

The permit will expire on May 1st and MUST be renewed each year with all paperwork listed above.

Applicant Information

Name:

First Name

Last Name

Address:

City

State/Province

Zip/Postal

Primary Phone Number:

Secondary Phone Number:

Email:

ATV Information

Make:

Model:

VIN#:

Permit #:

Acknowledgement

I have read the City of Breese ordinance that is provided on the website regarding this transportation permit. I understand that if I wish to operate this vehicle on the city streets that I am to renew this permit annually, which requires an inspection and proof of insurance. By electronically signing this application, I agree to maintain adequate insurance in accordance with the above-referenced ordinance.

Electronic Signature:

First Name

Last Name

Date

File Upload

Maximum file size: 516MB

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