Please complete the following. Attached additional sheets if necessary:

OFFICIAL USE ONLY
Check Number:_________ Check Amount: $_____________
Account Number:_____________________ Inl:___________

1. General Information

Name of Business

Name of Owner

Business Location

Name of On-Site Contact

Phone Number(s)

2. Cart Inventory (What is the number of carts maintained on your premises?)

[ ] 0-25 Carts

If you have checked this box, please complete Section 1 of this form (General Information), sign, date and return within 30 days from the date of the letter.

[ ] 26-100 Carts

If you have checked this box, please complete and submit the completed form with a check payable to the City of San Jose in the amount of $ 200. Return within 30 days from the date of the letter.

[ ] 100 Plus Carts

If you have checked this box, please complete and submit the completed form with a check payable to the City of San Jose in the amount of $ 200. Return within 30 days from the date of the letter.

3. Community Outreach

[ ] Signs posted in prominent places near doors and/or parking lot exits	[ ] Notice at Registers.	[ ] Other means of communication

4. Cart Signage

Every Cart owned or provided by any Owner must have a sign permanently affixed to the Cart that contains all of the following information:

1) Identity of Owner, business establishment, or both

2) The address or phone number of the Owner of the business

3) Notification to the public that the removal of the Cart from the Premises is a violation of State Law

establishment for Cart return.

Please indicate language and statement to be used and affixed to carts to comply with the above Ordinance standards:

5. Loss Prevention Measures

Please describe cart loss prevention measures
[ ] Electronic or other disabling devices	[ ] Courtesy clerks to accompany customer	[ ] Security personnel	[ ] Security deposit for use of Cart
Other: Please Describe

6. Mandatory Retrieval

Each Prevention Plan requires a plan for cart retrieval within 24 hours notification by the City of San Jose. Please describe your cart retrieval plan:

7. Employee Training

Please describe method of employee training on Abandoned Cart Prevention Plan

[ ] Staff Meetings

[ ] Posting in Employee Areas

[ ] Employee Orientation

[ ] Other (describe below)

To the best of my knowledge the above information is true and accurate.

_____________________	______________________	_______________________	_______________________
Signature	Print Name	Title	Date

Return completed form with fee to:
The City of San Jose
Abandoned Cart Program
170 West San Carlos Street, 4th Floor
San Jose, CA. 95113
Remember to:
[ ] Check that all portions of the form are completed
[ ] Attach additional pages if necessary
[ ] Include a check for $200.00 payable to the City of San Jose.