Taxicab Driver Application - Montgomery County Page 4
ADVERTISEMENT
1
2
3
4WE ARE ASKING ALL TRADE GROUPS TO RECOMMEND DRIVERS FOR NEW
OR RENEWAL IDENTIFICATION CARDS, IN ORDER TO ASSURE THAT
PASSENGERS WILL RECEIVE QUALITY CUSTOMER SERVICE.
/
I recommend
do not recommend _____________________________________________________________for a
Taxicab Operator Identification Card.
_____________________________________
__________________________________
______________________
Company Designee (Signature)
Company Designee (PRINT)
Date
If you do not recommend applicant for renewal, please explain: _________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
TAXICAB DRIVERS MUST NOT DENY SERVICE TO PERSONS WHO RIDE IN A
TAXICAB WITH A SERVICE ANIMAL. (In accordance with the Americans with Disabilities Act)
I have received this notice and agree to provide service to people with service animals.
_______________________________________________
_______________________________________
Applicant’s Signature
Date
PHYSICIAN’S CERTIFICATE
I certify that within the previous 30 days the applicant, ______________________________________________________
has been given a physical examination including a tuberculosis test and is free from any communicable disease. The applicant is
not subject to any physical or mental impairment that could adversely affect his/her ability to drive safely or otherwise endanger
the public health, safety or welfare. Please provide tuberculosis test/x-ray results and the date administered.
If physician is unable to certify the above, please explain: ____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
AFFIX
____________________________________
_______________________________________________
Date
DOCTOR’S
Signature of Physician
OFFICE
____________________________________
_______________________________________________
STAMP
Physician’s Address
Physician’s License Number
HERE
____________________________________
_______________________________________________
Physician’s Phone Number and FAX Number
State of Issuance
I solemnly swear or affirm under penalty of perjury that the information provided and
statements made in this application are true, correct and complete.
_______________________________________________
_______________________________________
Applicant’s Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related Categories
Parent category: Legal