Answer: Yes or No if Yes please fill out below:
OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 Email: Licensing@tohmail.org
PRIVATE CARTERS LICENSE
RENEWAL
FIRST TIME
*
Rev. 12/17
* Must fill out Experience
Office Use Only
APPLICATION #
FILING FEE
DATE
VEHICLE LIC. #
TO
ISSUED
FEE PAID $
Individual Owner
Name of applicant:
Address: Email:
Exact location of garage:
Corporation, or trade name:
Main office:
Incorporated ?
Partner or
President
Does any person other than listed above have any interest in this business ?
If Yes, attach statement explaining their connection with this business.
Partner or
Vice President
Partner or
Secretary
Partner or
Treasurer
Date: / /
YES
Corporation, Co-partnership or Individual using a trade name
Phone #
Phone # ( ) -
Corporation
State:
NO
YES NO
Please Print Clearly
If corporation, co-partnership or individual using a trade name, �ill in blank spaces below
Co-Partnership
Name Address
Please indicate type of ownership
Were you, or any member of firm or corporation, ever convicted of any crime or offense other than traffic infractions ?
What Crime or Offense ?
When ? Where? Penalty Imposed?
Rev. 12/17
Sworn to before me this
Day of 20
NOTARY PUBLIC
* State Experience of Applicant:
The following Certificates must be submitted with your application.
1. Certificate of insurance – Automobile Bodily Injury $1,000,000/$3,000,000.
2. Certificate of insurance – Automobile Property Damage $ 500,000.
3. Certificate of Workmen’s Compensation or Waiver if self employed.
4. Certificate of Workmen’s Disability or Benefits if self employed.
I solemnly swear to the truth of the above statements, and do hereby certify that I have read and agree to abide by the terms of Article IV of
Chapter 128, Code of the Town of Hempstead, entitled “ Solid Waste Management.” I further understand, pursuant to Article IV,
Chapter 128, that all acceptable solid waste generated within the Town of Hempstead, must be delivered to a Town of Hempstead solid waste
management facility.
Year
Make Type Body
Unladen
Weight
Capacity
Owners
Veh. I.D. #
N.Y. State
Veh. I.D. #
N.Y. State
Lic. Plate #
New License #
Please supply additional paper if necessary
Office Use Only
Signature of Applicant Title
Issued under the direction of
KATE MURRAY, TOWN CLERK
Deputy Town Clerk
By
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