This declaration is to affirm that________________________________________

(Name of for-profit food Vendor)

Is requesting exemption from the State Law requirements for Occasional Food Vendors under the provision of Section 27521 (b)(1) of the California Uniform Retail Food Facilities Law, and will be giving food at:

For the benefit of the Long Beach Kids Connection Inc.

I certify that the above is true and correct to the best of my knowledge and belief. I further certify, under penalty of perjury, that the above named for profit food vender will receive no monetary benefit other than that resulting from recognition from participating in the event.

Printed Name_______________________________________Phone_______________________

Address: ________________________________________________________________

City____________________________________State:________Zip_________________

CA Drivers License Number: __________________________DOB:_________________

Signed_____________________________________________Date_________________

Title____________________________________________________________________