Taxicab Driver'S Permit Application Page 3
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3List the addresses of your previous residences for the past five years
:
(include street, city, state, and zip code)
List the names and addresses of your previous employers for the past five years
:
(include street, city, state, and zip code)
AUTHORIZATION TO OBTAIN INFORMATION
I have authorized the County of Henrico, Police Division to perform a background investigation in connection with this
application. This investigation may include information as to my criminal convictions, if any, Division of Motor
Vehicles records, previous employers, medical records, and other appropriate sources.
I understand that, in accordance with Henrico County Code Sections 21-70 and 21-72, knowingly making a false
statement on this application may result in this permit being revoked or denied, in addition to being a misdemeanor as
defined in Henrico County Code Section 21-20.
Applicant’s signature: ______________________________
Date: ______________________________
State of Virginia
County of Henrico
On this ______ day of __________________ 20____ who name is signed to the foregoing instrument, personally
appeared before me, acknowledged the foregoing signature to be his/hers, and having been duly sworn by me, made
under oath that statements made in the said instrument are true.
Notary public: _____________________________________
My commission expires on: __________________________
Date permit issued: _________________________________
Permit number: ____________________________________
HCPD-117B Page 2 of 2
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