Base Operator Vehicle Affiliation Letter Template

WESTCHESTER COUNTY TAXI & LIMOUSINE COMMISSION

Department of Public Safety • 112 East Post Road • White Plains, New York 10601 • (914) 995-8400

MONDAY through FRIDAY 9:00 am - 1:00 pm

BASE OPERATOR VEHICLE AFFILIATION LETTER

OFFICE USE ONLY OFFICE USE ONLY

Fee: $______

VP # ____________________

Deposit #_________________ Payment Type: M O / Check / CC

PREVIOUS VP # _______________ Rec'd By: ______________Date: ______________________ Deposit Date_______________

The affiliation of the Vehicle listed below has changed as follows: O Add Vehicle

O Cancel Vehicle

CHANGE EFFECTIVE ONLY UPON RECEIPT AT WCTLC OFFICE

Vehicle Owner: _________________________WCTLC Permit # ___________________________________

Address: ____________________________City: ______________________ State: ______ Zip Code: _____

VIN # ____________________________ Plate # ______________ State: _____ Year:______Make:_____

Base Station Name: _________________________ WCTLC Permit # ______________________________

Address: ____________________________ City ______________________ State _____ Zip Code _______

A completed copy must be kept on file at the Base Station.

In accordance with §500.24 of the WCTLC Rules & Regulations: “The WCTLC must be notified by the base station as to

the addition or deletion of an affiliated driver or vehicle from its roster. Failure to notify the WCTLC of this change may

result in a fine of $100 per violation.

THIS FORM MUST BE NOTARIZED WITHIN 30 DAYS OF DATE OF FILING

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 that the

applicant designates any driver of the for-hire vehicle listed in this application to accept said service or process on behalf of the applicant. The applicant also agrees 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 listed herein to welfare and compliance inspections. 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:_______________________________________________

Base Operator Manager / Owner

Signature

Sworn to before me this _______ day of ____________, 20___,

State of New York

)

County of ____________))ss:

________________________________________

Notary Public Signature / STAMP________________________________

WCPD 413c (12/11)

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