OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 email: licensing@tohmail.org
TAXI CAB OWNER
RENEWALFIRST TIME
Rev. 12-14 W
Individual Owner
Name of applicant: DBA
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:
Rev. 12-14 W
Certificate of insurance must be attached showing coverage
on all vehicles’ public liability insurance
Are there any unpaid judgements outstanding against the applicant? ANSWER
If yes, attach separate paper stating amount unpaid and nature of the transaction or act giving rise to said judgements.
Include location of court and date on which judgement was entered.
List all violations of any traffic law, ordinance or regulation for which you or any member of firm or corporation
have been arrested or convicted within the past 18 months.
Were you, or any member of firm or corporation, ever convicted of any crime or offense other than traffic infractions ?
Describe below each vehicle for which application is made for a taxicab license.
Property damage insurance
Amount:
Policy #:
Company:
Amount:
Policy #:
Company:
I solemnly swear to the truth of the above statements
Sworn to before me this
Day of
20
NOTARY PUBLIC
YES NO
Signature of Applicant
Title
Date
Violation
Name and Location of Court
Date
Violation
Name and Location of Court
Penalty imposed
Car #
Make Model
Seating
Capacity
Vin #
N.Y. State
Lic. plate #
Current taxi #
New License #
NUMBER OF VEHICLES
APPLICANT INTENDS
TO OPERATE:
Please supply additional info if needed
Office Use Only
Last Four Only
click to sign
signature
click to edit
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