CITY OF WEST LIBERTY GOLF CART PERMIT APPLICATION

CITY OF WEST LIBERTY GOLF CART PERMIT APPLICATION
Date

MonthDayYear
Name of Applicant
Address of Applicant
Phone Number of Applicant
Email Address of Applicant
example@example.com
Date of Birth

MonthDayYear
Current Age
Driver's License #
Expiration Date

MonthDayYear
Date
Name of Golf Cart Owner
ATV/UTV/Golf Cart Information:
Make
Model
Year
Serial Number
Liability Insurance Company
Policy #
Expiration Date

MonthDayYear
Date
I hereby state that the golf cart to be operated upon City streets in West Liberty shall be in good mechanical condition, thoroughly safe for transportation of passengers, and equipped with:

All equipment required of an ATV by the Code of Iowa, including Chapter 3211, Chapter 324, and all other applicable parts of the Iowa Code: An orange safety flag, the top of which shall be a minimum of six (6) feet from ground level and extend a minimum 2 feet above the highest point of the (golf cart), adequate brakes, steering apparatus, head, tail, horn, brake lights (golf carts: street legal light kit), rear view and/or side mirrors, tires, adequate exhaust and muffler system. PER CITY CODE ORIDINANCE 20210420-02 effective August 20, 2021.
I acknowledge I have received and read a copy of the City of West Liberty Golf Cart Ordinance and will abide by the regulations set forth in the Ordinance.
I agree to affix permit tag on the "LEFT" (drivers' side) rear wheel well or similar component.
I agree to provide or update liability insurance information to the City of West Liberty if there is a change in policies or upon policy renewal.
I understand that permits may be suspended or revoked upon violation of the conditions of the permit or abuse permit privileges. There will be no refund of the permit fee.
Signature of Applicant

Clear
GOLF CART PERMIT

Permit Fee: $30.00
Permit Valid Until: July 01, 2022

Maintain your copy of this form with you or on the golf cart when operating machine.
Should be Empty: