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1. Have you been convicted of a crime since your last WCTLC registration?

[ ] Yes [ ] No

This includes, but is not limited to, misdemeanors, felonies, and conditional discharges. If yes, you must provide date of conviction,

police agency, charge, disposition, court date and any other pertinent information:_______________________________________

________________________________________________________________________________________

2. Have you received a conditional discharge from a court of law since your last renewal? If yes, please explain:[ ] Yes [ ] No

3. Do you currently have any criminal charges pending against you?

[ ] Yes [ ] No

If yes, you must provide police agency, charge, date charge was filed, scheduled court date, and any other pertinent information:

________________________________________________________________________________________

4. Has any DMV driver license held by you been suspended or revoked since your last WCTLC registration?

[ ] Yes

[ ] No

This includes, but is not limited to, suspensions for parking tickets and insurance lapses. If yes, you must provide date, reason,

disposition, and any other pertinent information:

________________________________________________________________________________________

5. Have you been convicted of any traffic infractions since your last WCTLC registration?

[ ] Yes [ ] No

This includes, but is not limited to, misdemeanors, felonies, and conditional discharges. A plea of guilty is the equivalent to a finding

of guilty after trial. If yes, you must provide date of conviction, police agency, charge, disposition, court date and any other pertinent

information:

__________________________________________________________________________________________________________

6. Do you currently have any traffic infractions pending? If yes, please provide the details.:

[ ] Yes [ ] No

_________________________________________________________________________________________

7. Has any Taxi and/or For-Hire permit held by you been denied, suspended or revoked in any jurisdiction since your last

WCTLC registration?

[ ] Yes [ ] No

This includes, but is not limited to, Westchester County, New York City, and Nassau County . If yes, you must provide date, agency,

charge, disposition, and any other pertinent information:

DRIVER IDENTIFICATION INTERPRETER INFORMATION

Any individual who is assisting the applicant in completing this application MUST complete this section.

If you are helping the applicant complete this application, you are responsible for reading and interpreting the application, in its

entirety, to the applicant. If you do not understand anything on the application, you are responsible for calling the Taxi & Limousine

Commission at the phone number listed on the front of this application for clarification. The interpreter must sign and print name, as

well as give address and daytime (9AM-5PM) phone number below. Illegible entries will not be accepted.

________________________________________

_____________________

Name

Phone # (9AM – 5PM)

Print Name of Interpreter

__________________________________________________________________________

Home Address

Street

Apt/Unit #

City

State

Zip

_________________

:__________________________________

Dated:

Signed

Interpreter’s Signature

In consideration of the granting of the permit hereby applied for, the applicant agrees that service of any paper, notice, letter, summons, complaint

or legal process of any kind or nature may be made by the County of Westchester or any department thereof, upon the person to whom the permit

is issued by leaving a copy of any such paper, notice, letter, summons, complaint, or legal process with any person located at the address

designated in his/her application. It is further agreed by applicant that (s)he will conform to all rules and regulations of the Westchester County

Taxi & Limousine Commission governing the type of permit for which this application is submitted. In addition, applicant understands that

acceptance of this permit subjects the for-hire vehicle driven by the driver listed herein to welfare and compliance inspections.

I hereby affirm Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, all the

information is true, correct and complete. I understand that if this application is missing or has incorrect information, my application will be

rejected and that any fees I paid will not be refunded. If I want, I can re-apply with a corrected application including the required application fees. I

also know that under the law, all license applications are public records and may be disclosed, including this application and all other documents

and information filed with it; and I understand and agree that the Westchester County Taxi & Limousine Commission may verify any documents

and information I provide, including verification of my social security number by the Social Security Administration, and Child Support case status if

applicable in connection with this application. Applicant further understands that, pursuant to §210.45 of the NYS Penal Law, it is a crime

punishable as a Class “A” misdemeanor to knowingly make a false statement herein.

Application Date: ________________

Signed: ______________________________________________________

Applicant’s Signature

NO RENEWAL APPLICATION WILL BE ACCEPTED BEYOND EXPIRATION DATE

)

ALL APPLICATION FEES & MATERIALS ARE NON-REFUNDABLE, NON-RETURNABLE

WCPD373 (Rev 09/2015

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