OFFICE OF THE TOWN CLERK
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 email: licensing@tohmail.org
TOW CAR DRIVER
RENEWALFIRST TIME
*
Rev. 12-14 W
1. Name:
Tel #: ( ) -
2. Legal
Address:
E-Mail
Address:
3. Years living
at above address:
7. Are you
a US citizen ?
10. Race:
16. Prominent scars or distinguishing marks? 17. Have you any mental or physical ailment?
18. Were you ever convicted of any crime or offense other than traffic infractions ? - Answer
19. Do you have any charges pending against you ?
20. List ALL violations of any traffic law, ordinance or regulation for which you have been convicted within the past 18 months:
21. Was your operators or chauffeurs license ever suspended or revoked ?
If YES, state date, period of suspension and cause.
22. Give the name and address of your employer (s), and your occupation (s) for the past Ten (10) years. Give name of
present employer first.
Please supply additional info if needed
Please supply additional info if needed
Please supply additional info if needed
11. Height:
Date
Date
Place of Arrest
Charge
8. Native or
naturalized:
9. If Naturalized When
& Where:
4. DOB:
5. Age:
6. Place
of Birth:
6A. Social Security #:
/ /
Yrs.
I solemnly swear to the truth of the above statements
Sworn to before me this
Day of
20
20
20
20
SUBMIT TWO PHOTOS
TAKEN WITHIN THE
PAST THIRTY DAYS
EACH 1 x 1
SHOWING ONLY NECK
SHOULDERS AND
UNCOVERED HEAD
SUBMIT TWO PHOTOS
TAKEN WITHIN THE
PAST THIRTY DAYS
EACH 1 x 1
SHOWING ONLY NECK
SHOULDERS AND
UNCOVERED HEAD
* First time applicant must complete reverse side
1/2’’ 1/2’’
Date Violation
Violation
Place of Arrest
Name & location of court Penalty imposed
Penalty imposed
Date
Employer
NOTARY PUBLIC
Address Occupation
12.Weight: 13. Eye Color: 14. Hair Color: 15. Complexion:
Office Use Only
LICENSE #
ASSIGNED
ISSUED
N.Y. STATE LICENSE: TYPE
VALIDATION #
EXPIRES
YES NO
YES NO YES NO
YES NO
YES NO
YES NO
Signature of Applicant
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signature
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Signature Business
Residence Business Address
RESIDENT 1:
RESIDENT 2:
Is the applicant related to you ? If so, give particulars
Has the applicant ever been in your employ ?
Would you employ this applicant now if the opportunity arose?
I, , do hereby certify that I have known
the applicant herein named, for a period of One ( 1 ) year or more, that I have observed the applicants
conduct during the period so stated and found the applicant to be honest, sober and of good character, civil
in manner and behavior; that I know nothing to the applicant’s prejudice, and recommend the applicant
as a fit person to be licensed to drive a tow car vehicle.
Signature Business
Residence Business Address
Is the applicant related to you ? If so, give particulars
Has the applicant ever been in your employ ?
Would you employ this applicant now if the opportunity arose?
I, , do hereby certify that I have known
the applicant herein named, for a period of One ( 1 ) year or more, that I have observed the applicants
conduct during the period so stated and found the applicant to be honest, sober and of good character, civil
in manner and behavior; that I know nothing to the applicant’s prejudice, and recommend the applicant
as a fit person to be licensed to drive a tow car vehicle.
The following voucher completed by two ( 2 ) residents of Nassau County who
have known you for a period of at least one ( 1 ) year and are not related to you.
* ALL FIRST TIME APPLICANTS MUST HAVE
Rev. 12-14 W
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signature
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click to sign
signature
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