Taxicab Driver Application - Montgomery County Page 3
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4EVER, AT ANY TIME
3. DO YOU HAVE A CRIMINAL CASE PENDING OR HAVE YOU –
– BEEN CONVICTED OF,
PLED GUILTY, NO CONTEST TO, OR WERE PLACED ON PROBATION WITHOUT A FINDING OF GUILT? ........
YES
NO
PLEASE LIST. IF YOU NEED ADDITIONAL SPACE, CONTINUE ON A SEPARATE SHEET.
DATE
OFFENSE
DISPOSITION/STATUS
CITY/COUNTY
STATE
4. HAVE YOU EVER BEEN REQUIRED TO REGISTER AS A SEX OFFENDER? ...............................................
YES
NO
WHEN, WHERE, AND WHY: ____________________________________________________________________________
5. NAME OF THE TAXICAB COMPANY FOR WHICH YOU WILL DRIVE: ___________________________________________
6. HAVE YOU EVER HAD A DRIVER’S LICENSE IN ANY OTHER STATE OR COUNTRY? .................................
YES
NO
WHERE AND WHEN: _________________________________________________________________________________
7. HAS MVA/DMV EVER SUSPENDED, REVOKED OR DENIED YOUR DRIVING PRIVILEGES? .....................
YES
NO
WHEN, WHERE AND WHY? ____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8. HAVE YOU EVER HAD A TAXICAB DRIVER’S ID CARD OR SEDAN DRIVER’S LICENSE? ..........................
YES
NO
WHERE AND WHEN: _________________________________________________________________________________
IF YES TO #8, WAS YOUR TAXI DRIVER’S ID CARD OR SEDAN DRIVER’S LICENSE
EVER DENIED, SUSPENDED OR REVOKED? ................................................................................................
YES
NO
WHY AND WHEN?: __________________________________________________________________________________
___________________________________________________________________________________________________
9. HAVE YOU SUFFERED ANY SERIOUS ILLNESS OR BODILY INJURY SINCE YOUR
LAST APPLICATION? .........................................................................................................................................
YES
NO
EXPLAIN: ___________________________________________________________________________________________
___________________________________________________________________________________________________
10. HAVE YOU EVER PLED GUILTY OR BEEN CONVICTED OF ANY OFFENSE INVOLVING
DRIVING UNDER THE INFLUENCE OR DRIVING WHILE INTOXICATED? ....................................................
YES
NO
LIST DATE(S) AND JURISDICTIONS: _____________________________________________________________________
___________________________________________________________________________________________________
11. ARE YOU ADDICTED TO ALCOHOL OR NARCOTIC DRUGS? ......................................................................
YES
NO
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