(Please Print in Blue or Black Ink)
Golf cart owner's name(s): _____________________________________________________________
Owner's Physical Address: ____________________________________________________________
   City/Town: __________________________ State: _________________ Zip: ________________
Owner's Mailing Address: _____________________________________________________________
   City/Town: ___________________________State: _________________ Zip: ________________
Owner's Telephone No. Daytime. ( ) __________________ Night time:( ) ___________________
Owner's Driver License Number: ________________________________ State:__________________
Make of golf cart (Mfg): ______________________________________________________________
Color of golf cart: __________________________________ Model (Year): _____________________
Serial Number of golf cart: ____________________________________________________________
Assigned number of golf cart: __________________________________________________________
I have received, read and understand the "Golf Cart Ordinance." I have paid the registration fee for the above cart and agree to additional assessments as may be required in support of this ordinance. I acknowledge that I will assume all liability, and am fully responsible for the operation of the above cart on the streets and roads in the Town of Pineville. I also acknowledge that the Town of Pineville, in providing this privilege, is in no way endorsing the operation of this cart on the streets and roads, and does not and will not assume any liability in the operation of the cart. I agree to indemnify and hold harmless the Town of Pineville for any and all liability arising from the use of this golf car/cart. I also understand that the Pineville Police Department's interpretation of all the rules and regulations is final. I will insure that the assigned proof of compliance will remain attached to the driver's side of the cart at all times. I furthermore insure that I will obey all the rules and regulations set forth by the Town of Pineville concerning the operation of a cart within the town limits.
______________________________________       ________________________________________
Owner's Signature                   Date
For Town's Use Only
Approved by:    Chief of Police    Town Administrator    Other: _____________________
______________________________________       ________________________________________
Signature                     Date
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Locking brakes
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Reverse warning device
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Main power switch
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Either hip restraints or hand holds
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Lighting devices as stated in §§ 73.01 through 73.04 (for night use):
"Two lighted lamps, one on each side of the front of the golf cart [...] and two red lamps on the rear"
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Manufacturer's serial number plate
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Rear vision mirrors
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Proof of insurance
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$25 registration fee paid
(Ord. 2008-04, passed 9-9-2008)