Form Wcpd322 - Medical Provider Waiver Application - Westchester County Taxi & Limousine Commission
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4WESTCHESTER COUNTY TAXI & LIMOUSINE COMMISSION
Department of Public Safety • 112 East Post Road • White Plains, New York 10601 • (914) 995-8400
MEDICAL PROVIDER WAIVER APPLICATION
OFFICE HOURS: 9AM – 1PM MONDAY thru FRIDAY
RENEW BY MAIL
[ ] New
[ ] Renewal
[ ] Replacement
[ ] Transfer
OFFICE USE ONLY
Date Rec:
DP #
Deposit #
Applicant Fee $
MO
CK
CC
Fingerprint Fee $
REC’D BY:
OWNER INFORMATION
Name of Vehicle Owner________________________________________________________________________________________
Give full name as it appears on the Title / Registration / Lease Agreement
Social Security Number ________________________________
Date of Birth_______________________________________
Month
Day
Year
Federal ID Number (Business Entities Only) ________________________________________________________________________
Owner Address_______________________________________________________________________________________________
City/Town______________________________________________________State__________________Zip Code_______________
Telephone Numbers: (H) (_____)________________ (W) (_____)__________________(C) (______)________________
Did your company provide medical transportation during the previous tax year ?
[ ] Yes [ ] No
If you provided medical transportation service last year then you must supply copies of IRS form 1099 as instructed on page four
Of the instructions.
If vehicle is owned by one individual, check appropriate box below and complete this form. If 2 or more owners, a partnership, or a
corporation, check appropriate box and have each owner or partner and anyone owning more than 10% of stock in the corporation
complete a separate owner portion of this form
WCPD374 (Rev 11/ 07)
Page 1 of 4
Plate #
__________
State
Type of Ownership: (choose one)
VIN #
_
__________ ___
[ ] Sole Proprietorship
Year/Make
_________
____/Color_______
[ ] Partnership
Seating Capacity ___________________
[ ] Corporation
NYS / DOT Inspection No.__________________
Inspection Expiration Date____________________________
WCPD322 (Rev 09/2016)
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