OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 email: licensing@tohmail.org
LIMOUSINE OWNER PRIVATE LIVERY VAN
RENEWALFIRST TIME
Rev. 1-16
Individual Owner
Name of applicant:
Address:
Exact location of depot or dispatching office:
Corporation, or trade name:
Main office:
Incorporated ?
Partner or
President
What connection has above named individual, co-partnership or corporation
with ownership or operation of vehicles described herein ?
Partner or
Vice President
Partner or
Secretary
Partner or
Treasurer
Date: / /
YES
Corporation, Co-partnership or Individual using a trade name
Business hours Business phone #
Phone # ( ) -
Phone # ( ) -
Corporation
State:
Office Use Only
APPLICATION #
FILING FEE
VEHICLE LIC. #
TO
ISSUED
FEE PAID $
Certificate #
Owner Holding company Lessee Operating company
NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
If corporation, co-partnership or individual using a trade name, �ill in blank spaces below
Co-Partnership
Name Address
Birth place Age Date CourtNaturalized
Name Declared Intentions
To be �illed out in relation to each individual or partner and each of�icer of corporation making this application
Citizenship
Please indicate type of ownership
email address:
