Application For A New Broker/ Agent License, Renewal License And Change Of Information (Page 5 of 6) in pdf

Application For A New Broker/ Agent License, Renewal License And Change Of Information Page 5

VI. AFFIRMATION

REQUIRED TO BE COMPLETED AND SIGNED BY ONE OFFICER REPRESENTING THE OWNER(S).

I have submitted this affirmation at the request of the New York City Taxi & Limousine Commission (TLC).

I am currently an officer of __________________________________________________________________.

(Name of Company)

I further agree to notify the TLC promptly if any information concerning the business to which the

license is being issued is amended or otherwise charged.

“I hereby affirm, under penalty of law, that I have examined and reviewed the information in the submitted form(s) or

application(s), including any supplemental form(s) and/ or document(s) and that these document(s) and or statement(s) do

not contain any untrue statement(s) nor are they missing any material information and/ or fact(s). I also acknowledge and

understand that any false statement(s) submitted is punishable under the law and may result in a denial of an application or

the suspension or revocation of an existing license/permit.”

Name (print): _____________________________________________________________________________________

Signature: _______________________________________________________________________________________

Today’s Date: ______________________________

Title: ______________________________________

Agent / Broker New, Renew, Change of Information Application 11.16.15

Application For A New Broker/ Agent License, Renewal License And Change Of Information Page 5