REQUEST FOR PERMISSION TO CONDUCT
STATE OF CONNECTICUT
SPECIAL INTEREST ACTIVITY ON PREMISES OF THE DEPARTMENT
DEPARTMENT OF MOTOR VEHICLES
LS-5 REV. 6-2001
LEGAL AND DRIVER SERVICES
On The Web At ct.gov/dmv
SECTION 1 - NAME AND TYPE OF ORGANIZATION
NAME OF INDIVIDUAL REQUESTING PERMISSION
DATE OF REQUEST
NAME OF ORGANIZATION
TELEPHONE NUMBER
ADDRESS
(Number and Street)
(City or Town)
(State)
(Zip Code)
IS THE ORGANIZATION:
IN WHAT STATE(S)?
PARTNERSHIP
INCORPORATED
IRS STATUS (Attach copy of ruling)
SECTION 2 - DESCRIPTION OF PROPOSED ACTIVITY
DESCRIPTION OF PROPOSED ACTIVITY. PLEASE INDICATE MEANS OF COMMUNICATIONS TO BE USED. PLEASE ATTACH A COPY OF MATERIAL TO BE DISTRIBUTED, IF AVAILABLE.
SECTION 3 - LOCATION REQUEST
LOCATION REQUESTED IN WHICH
DATES REQUESTED
HOURS REQUESTED
TO CONDUCT THIS ACTIVITY
SECTION 4 - INDIVIDUALS DESIGNATED BY ORGANIZATION
NAME OF CONTACT PERSON RESPONSIBLE FOR PROPOSED ACTIVITY
ADDRESS
(Number and Street)
(City or Town)
(State)
(Zip Code)
TELEPHONE NUMBER
NAME RESIDENT AGENT FOR SERVICE OF PROCESS
ADDRESS
LIST NAMES AND ADDRESSES OF INDIVIDUALS TO BE INVOLVED
1.
2.
3.
4.
5.
6.
SECTION 5 - SIMILAR ACTIVITIES (Past Experience)
PLEASE LIST SIMILAR ACTIVITIES CONDUCTED WITHIN THE PAST 12 MONTHS. INDICATE ADDRESS AND TYPE OF LOCATION AND PRESENT STATUS OF EACH.
SECTION 6 - CERTIFICATION
By its signature on this application, the applicant affirms that it (or its duly authorized representative) has read the attached guidelines and will comply with the guidelines as a
condition of the permission which the department may grant. The applicant further attests that the statements and information contained in this application are true and correct.
AUTHORIZED SIGNATURE (Official representing organization)
DATE TITLE/AFFILIATION WITH ORGANIZATION
DATE SIGNED
X
REQUEST FOR PERMISSION TO CONDUCT
STATE OF CONNECTICUT
SPECIAL INTEREST ACTIVITY ON PREMISES OF THE DEPARTMENT
DEPARTMENT OF MOTOR VEHICLES
LS-5 REV. 6-2001
LEGAL AND DRIVER SERVICES
On The Web At ct.gov/dmv
SECTION 1 - NAME AND TYPE OF ORGANIZATION
NAME OF INDIVIDUAL REQUESTING PERMISSION
DATE OF REQUEST
NAME OF ORGANIZATION
TELEPHONE NUMBER
ADDRESS
(Number and Street)
(City or Town)
(State)
(Zip Code)
IS THE ORGANIZATION:
IN WHAT STATE(S)?
PARTNERSHIP
INCORPORATED
IRS STATUS (Attach copy of ruling)
SECTION 2 - DESCRIPTION OF PROPOSED ACTIVITY
DESCRIPTION OF PROPOSED ACTIVITY. PLEASE INDICATE MEANS OF COMMUNICATIONS TO BE USED. PLEASE ATTACH A COPY OF MATERIAL TO BE DISTRIBUTED, IF AVAILABLE.
SECTION 3 - LOCATION REQUEST
LOCATION REQUESTED IN WHICH
DATES REQUESTED
HOURS REQUESTED
TO CONDUCT THIS ACTIVITY
SECTION 4 - INDIVIDUALS DESIGNATED BY ORGANIZATION
NAME OF CONTACT PERSON RESPONSIBLE FOR PROPOSED ACTIVITY
ADDRESS
(Number and Street)
(City or Town)
(State)
(Zip Code)
TELEPHONE NUMBER
NAME RESIDENT AGENT FOR SERVICE OF PROCESS
ADDRESS
LIST NAMES AND ADDRESSES OF INDIVIDUALS TO BE INVOLVED
1.
2.
3.
4.
5.
6.
SECTION 5 - SIMILAR ACTIVITIES (Past Experience)
PLEASE LIST SIMILAR ACTIVITIES CONDUCTED WITHIN THE PAST 12 MONTHS. INDICATE ADDRESS AND TYPE OF LOCATION AND PRESENT STATUS OF EACH.
SECTION 6 - CERTIFICATION
By its signature on this application, the applicant affirms that it (or its duly authorized representative) has read the attached guidelines and will comply with the guidelines as a
condition of the permission which the department may grant. The applicant further attests that the statements and information contained in this application are true and correct.
AUTHORIZED SIGNATURE (Official representing organization)
DATE TITLE/AFFILIATION WITH ORGANIZATION
DATE SIGNED
X
GUIDELINES FOR CONDUCT OF SPECIAL INTEREST ACTIVITY
ON PREMISES OF THE DEPARTMENT OF MOTOR VEHICLES
PURPOSE. The building and grounds of the Department of Motor Vehicles headquarters and branch offices are facilities devoted to
the official business of the Department. Due to the volume of public business conducted on these premises, certain special interest
groups have found then attractive locations at which to contact the general public on issues of concern to such groups. It is the
purpose of these guidelines to provide for the safety and convenience of all persons on the premises of the Department, to provide
for the orderly, effective and efficient administration of the official business of the Department of Motor Vehicles and to accommodate
the exercise of the constitutionally guaranteed right to freedom of speech enjoyed by all citizens.
1.
All persons or organizations wishing to enter upon premises of the Department of Motor Vehicles for purposes other than the
conduct of official business shall request permission of the Commissioner of Motor Vehicles, in writing, on the form provided.
Permission will be granted or denied in writing stating any special conditions attendant to permission or the reasons for denial.
2.
The written permission shall be retained and displayed on request for purposes of identification and examination.
3.
Permission for entry will be considered for purposes of the exercise of free speech right without regard to subject matter.
4.
Permission will be granted on a case-by-case basis depending on whether the organization's proposed activity unreasonably
interferes with the Department of Motor Vehicles normal activity.
5.
Permission will be granted to conduct special interest activity only at those locations at which such activity can be conducted
without danger to any person and without interference with normal business operations. Some branch offices have no suitable
site and permission will be denied for entry at such locations.
6.
Special interest sites have been pre-selected to ensure the safety, welfare and convenience of all concerned. All sites are out of
doors.
7.
Permittees may provide a suitable table not to exceed three feet by three feet and two chairs for their convenience.
8.
Permittees must display a single sign identifying the person or organization by name and address and the purpose of their
presence. The sign should be easily readable from a distance of ten feet and no larger than 3 x 3 feet.
9.
Permittees will confine their activity to the immediate area of the pre-selected site and will not expand their activity beyond this
authorized area.
10.
Permittees may verbally invite a passer-by to stop and consider the presentation sought to be made. If such invitation is
declined, no further invitation or invocation will be made and that person shall be allowed to pass without further comment or
interference.
11.
Permittees will at all times maintain a conversational tone and will not use any sound amplification, record or radio devices or
equipment.
12.
Permittees will not approach patrons outside the authorized area.
13.
Permittees shall not touch any person and shall not physically obstruct, verbally interfere or restrict in any way the free
movement of persons.
14.
Permittees may distribute free literature promoting and promulgating their cause in connection with their presentation, which
materials may contain requests or instruction for off-premises voluntary application for membership and financial support.
15.
Subject to the following conditions, permittees may solicit and collect donations, contributions, membership dues and fees,
and the price of any literature offered for sale.
If any solicitation is declined, no further solicitations will be made and that person shall be allowed to pass, without further
comment or interference. Permittees shall not engage in any commercial activity that is not clearly related to the dissemination
of ideas and information. Permittees recognize the interest of the Department in preventing the occurrence of fraud or theft,
and that any permittee who commits or is alleged to commit any such offense will be reported to the appropriate law
enforcement authorities.
16.
Permittees shall not allow litter to be discarded except in proper waste receptacles and will keep the area clean and free from
litter.
17.
Permittees shall not eat or drink while at the special interest activity site.
Unless exception is made by the Department, permitees may conduct special interest activity for a maximum of two (2) days in
18.
any six month period.
Application must be made at least seven (7) days prior to the first date on which special interest activity will be conducted.
19.
Violations of these guidelines will result in withdrawal of continued permission to conduct special interest activity.
These guidelines are subject to revision depending upon the need for further time, place or manner, rules or guidelines to ensure the
safety, welfare and convenience of all persons and non-interference with official business of the Department of Motor Vehicles.
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