Name:                        Date of Birth:

Address:

Phone: 

Sex: Male  Female

Driver's License Number:

                                                                                        Number, State, and Type

Have you ever been arrested and/or convicted?  Yes  No

If yes, Please provide date, location, charge, and court:

Has you license to operate a motor vehicle ever been suspended or revoked?  Yes  No

If yes, give full details:

Are you a member of the Armed Services?  Yes  No

Are you a United States Citizen?  Yes  No

Last or Present Employer: (Please provide name and address):

Length of residence in New York State: 

Have you previously been licensed in the City of Plattsburgh, New York to operate a taxi?  Yes  No

Have you ever had an application to operate a taxi denied?  Yes  No

If so, give date and reason:

Please list four references, including address, who will vouch for your character:

1)

2)

3)

4)

Notice: FALSE STATEMENTS MADE HEREIN ARE PUNISHABLE PURSUANT TO SECTION 210.45 P.L., AS A CLASS "A" MISDEMEANOR.  INCOMPLETE OR INACCURATE INFORMATION MAY BE A CAUSE FOR DENIAL OF YOUR APPLICATION.

APPLICANT SIGNATURE: ____________________________________     DATE: ______________

APPROVED:(    )    DISAPPROVED:(    )   ___________________________________________

                                                                                            NAME

                                                                     ___________________________________________

                                                                                            TITLE

DATE: ________________