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Please
read all instructions and then complete the following information and mail
to:
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Incorporated
Village of Farmingdale
PO Box 220 361 Main Street
Farmingdale, NY 11735
(516) 249-0093
www.FarmingdaleVillage.org
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INCORPORATED
VILLAGE OF FARMINGDALE
TAXICAB DRIVER
License Expires Annually August 31
Please type or print clearly.
Answer All Questions.
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License No.
MCR No.
Date
Approval
Village Clerk
Board of Trusties
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______________________
______________________
______________________
______________________
______________________
______________________
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| Name: |
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| Address: |
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How long have you resided at this
above address? |
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| Date of Birth |
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Place of Birth |
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Age |
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| Height |
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Weight |
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Color of Eyes |
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| Color of Hair |
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Complexion |
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| Prominent
scars or distinguishing marks |
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| Have you
any mental of physical infirmity? |
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| Where you
ever convicted of any crime or offense other than traffic
infractions? |
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| What
crime or offense? |
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| When? |
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Where? |
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| Penalty
assessed |
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List all violations or any traffic
law, ordinance or regulation for which you have been convicted
within the past 18 months.
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| DATE |
VIOLATION |
NAME & LOCATION OF COURT |
PENALTY |
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| Was your operator's
or chauffeur's license ever suspended or revoked? If yes, state
date, period of suspension, and cause: |
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| Give the name and address of your
employers, and your occupation for the past five years: |
| DATE |
EMPLOYER |
ADDRESS |
OCCUPATION |
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Sworn to before me this ___________________
day of ______________________20________
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I SOLEMNLY SWEAR TO THE TRUTH OF THE ABOVE
STATEMENTS. |
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______________________________________
Notary Public
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__________________________________________________
Signature of Applicant
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