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WESTCHESTER COUNTY TAXI & LIMOUSINE COMMISSION

Department of Public Safety • 112 E. Post Rd White Plains, New York 10601 (914) 995-8400

Service Window Hours Monday through Friday 9:00 am to 1:00 pm

APPLICANT REFERENCE FORM

NOTARIZED FORM MUST BE WITHIN THIRTY (30) DAYS OF FILING APPLICATION

NOTICE TO APPLICANT: You must submit three (3) Applicant Reference Forms filled out and signed by three (3) separate

individuals who are not related to you in anyway including through marriage. This form must be signed by the character reference

and his/her signature must then be notarized.

Supplying false information on this document may result in criminal charges being filed.

________________________________________________,

has filed an application to operate a for-hire

(Name of Applicant)

vehicle /business/municipal car in Westchester County, NY. The applicant has given your name as a reference. Please

complete this form and return it to the applicant upon completion.

1. Is the applicant related to you by blood or marriage?

[ ] Yes [ ] No

(If Yes, Stop here and return form to the applicant. This form cannot be completed by a relative of the applicant, as

described above.)

2. I have known the applicant for ________ years. If less than one (1) year, return form to applicant. This form

cannot be completed by anyone who has known the applicant for less than one (1) year.

3. Describe your relationship with the applicant: __________________________________________________________

4. How would you rate the applicant in the following areas? Place a check mark in the appropriate box.

Very High

High

Average

Below Average

Not Acceptable

Character

Honesty

Reliability

5. To the best of your knowledge, does the applicant use intoxicating beverages or drugs? [ ] Yes [ ] No

IF YES, please describe the extent of use: _______________________________________________________________

__________________________________________________________________________________________________

6. Would you recommend that the Westchester County Taxi and Limousine Commission grant the applicant a

permit?

[ ] Yes [ ] No

7. Please provide any further comment that you feel is relevant on the back of this form.

Print Name of Character Reference: ______________________________________________________________________

Address of Character Reference :____________________________________(City)_______________________(State)____

Cell phone___________________________ Home Phone _______________________ Business Phone __________________

Dated:_____________________

Signature of Character Reference:____________________________________

State of New York

)

________

____.

Sworn before me this

day of ______________________, 20

County of _______________)) ss:

______________________________________________________

Notary Public Signature

Note: Character References will be contacted be a member of the Westchester County Dept of Public Safety to discuss Applicant’s suitability

WCPD 327 (Rev. 11/11)

Applicant Reference Form - Westchester County Taxi & Limousine Commission, Department Of Public Safety

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