TELEPHONE
(508)
94
1-0200
Application for License to operate Taxi or Public Automobile
TO THE CHIEF OF POLICE, DATE:
I,
the undersigned, hereby apply for a license to operate Taxis in the City of Brockton,Massachusetts, as
required by Article
11,
"Drivers LicenseWSec.
27
of the revised ordinances of the City of Brockton,
Massachusetts, as adopted March 31, 1950 and effective May
1,
1950 and amendments thereto and as
required by said chapter 10 hereby furnish the following statement of facts:
ADDRESS:
DATE OF BIRTH: AGE: PLACE OF BIRTH:
HIGHT: WEIGHT: EYES: HAIR: COMPLEXION:
ARE
YOU A UNITED STATES CITIZEN:
ARE
YOU A VETERAN:
MA DRIVERS LICENSE NUMBER:
DATE OF EXPIRATION:
HAVE YOU BEEN ARRESTED OR SUMMONSED TO COURT
IN
THE PAST FIVE YEARS?
IF
YES, GIVE DATE, OFFENSE CHARGE, DISPOSITION
AND
NAME OF COURT:
HAVE YOU EVER HAD A PREVIOUS TAXI DRIVER'S LICENSE SUSPENDEDIREVOKED?
IF SO, GIVE CIRCUMSTANCES:
IS THIS APPLICATION A RENEWAL? YES: NO:
***MUST SUBMIT
A
LETTER OF INTENT TO EMPLOY BY THE TAXI COMPANY
**(Be advised,
a
full backgroundICOR1 check and drivers history check is done on all applicants)""
SIGNATURE OF APPLICANT:
(Signed under Penalties of Perjury)
**Office Use Only**
LICENSE
#
ISSUED:
DATE OF ISSUE:
