Kentucky Department of Agriculture
Division of Regulation and Inspection
111 Corporate Drive
Frankfort, Kentucky 40601
OFFICE: (502)
573-0282 FAX: (502) 573-0303
I T I N E R A R Y M O B I L E O P E R A T O R S
Kentucky Statutes KRS 247.234 and KAR 16:010-16:050 rules requires all owners and/or operators of an amusement ride(s) or device(s) to annually
submit at least 14 days in advance of operation
, along with a listing of rides/attractions. You can duplicate this form as needed and retain a copy for your records. Please list in chronological order i.e.: first playing first. Street addresses must be provided for each location. Inquires can be made by calling (502) 573-0282.
PROOF OF INSURANCE MUST BE IN OUR OFFICE BEFORE OPERATING ANY RIDES/ATTRACTIONS.
Company Name:
Address:
City:
State:
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
State
Zip:
Phone#:
Owner/Responsible Person:
Cell Phone#:
Notes:
ON SITE INFORMATION
Opening Date:
Closing Date:
Open Time:
Close Time:
Inspect Date:
Inspect Time:
Number Initial Inspections - Adult:
Kiddie:
Number Rides/Attractions Already Inspected to be Operated: Adult:
Kiddie:
Location:
Address:
City:
County:
ON SITE INFORMATION
Opening Date:
Closing Date:
Open Time:
Close Time:
Inspect Date:
Inspect Time:
Number Initial Inspections - Adult:
Kiddie:
Number Rides/Attractions Already Inspected to be Operated: Adult:
Kiddie:
Location:
Address:
City:
County:
ON SITE INFORMATION
Opening Date:
Closing Date:
Open Time:
Close Time:
Inspect Date:
Inspect Time:
Number Initial Inspections - Adult:
Kiddie:
Number Rides/Attractions Already Inspected to be Operated: Adult:
Kiddie:
Location:
Address:
City:
County:
Owner Signature (typing your name is your digital signature):
Date:
Email Address: