Contact Us AMUSEMENT RIDE & ATTRACTION BUSINESS IDENTIFICATION NUMBER APPLICATION Part 1 NOTE: Any application listing a P.O. Box in this section will be returned to the applicant. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Mailing Address: Is the mailing/Billing address the same as the physical address. If no, complete the following: Yes or No Yes No Billing/LICENSE RENEWAL ADDRESS: State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Part 2 I hereby apply for a permit to operate amusement rides/attractions as prescribed by the provisions of KRS 247.232 through KRS 247.236 and the rules and regulations of the Kentucky Department of Agriculture. Amusement ride means any mechanized device which carries passengers over a fixed or restricted course for amusement, pleasure, or excitement. Attraction means any building or structure over or through which people may walk, climb, slide, jump, or move that provides amusement, pleasure, or excitement. This does not include shows, games, or concessions. Please complete Attachment 1, List of Amusement Rides and Attractions, and submit with this application. There is a $50.00 annual registration fee. There is an inspection fee, and a $5.00 permit fee for each device to be assessed at the time of initial inspection. Make a check or money order payable to the Kentucky State Treasurer, in care of the KY Dept of Agriculture, Regulations and Inspections (R & I) 107 Corporate Dr., Frankfort KY 40601. Kentucky law requires an operator of an amusement ride or attraction to maintain pre-opening daily checklists and maintenance records. Part 3 INSURANCE - The applicant must provide either a Certificate of Insurance issued by the insurance Company or a copy of the actual insurance policy for the minimum amount of $1,000,000.00, as prescribed by KRS 247.234. In either case, the following information must be contained on the certificate or within the policy: 1. Time period of coverage. 2. Limits of the policy. 3. A 30-day cancellation notice. 4. Name of ride(s) insured. If the policy covers all rides operated by the insured, regardless of the number, the policy or certificate must contain this statement. Insurance Company Please list your ride attraction Name, manufacturer and serial number. Ride Attraction Name, Manufacturer, Serial number Part 4 Please check the following to confirm your acknowledgement of the following duties. I understand that I must maintain a copy of this application on site for KDA inspectors. I understand that I must maintain a copy of the insurance policy on site for KDA inspectors. I understand that I must maintain a copy of maintenance records for each ride or attraction on site for KDA inspectors. I understand that I must maintain a copy of daily pre-opening checklists on site for KDA inspectors. I understand that I must maintain a copy of the most current manufacturer’s manual and bulletins for each ride or attraction on site for KDA inspectors, and that operators must be familiar with these manuals and bulletins. I understand that I must maintain and submit an up-to-date itinerary of operation to the KDA prior to the operation of rides or attractions. I understand that the itinerary form is on the KDA website and may be submitted electronically. I understand that all fees must be submitted to the KDA prior to an initial inspection. I have read and understand all statutes and regulations pertaining to amusement rides and attractions. I understand that this application will be returned to me if all fields are not properly completed. I hereby acknowledge that I have read this application and affirm that the statements made herein are true and correct to the best of my knowledge. Electronic Signature: Print Paper Form