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NY State Department of Health Contact Information

List the contact name and address of NY DOH for whom your vehicle provides transportation services.

1. Name __________________________________________ Phone No. ____________________________

Address ______________________________________________________________________________

Street

City

State

Zip

AUTHORIZED PERSONNEL INFORMATION

If the name, which appears on the DMV registration is that of a business, then this section must be completed and signed by a controlling

partner, owner or authorized personnel of the business. By signing this application the person named below attests that he/she is

authorized by the business to enter into an agreement on behalf of the business.

Name of Authorized Personnel ____________________________________________________________________________________

LAST

FIRST

Title of Authorized Personnel _______________________Date of Birth ______ / ______ / ______ SS# _________________________

Day

Home Address _________________________________________________________ Office Phone Number_____________________

Street Address

City

State

Zip

The vehicle listed herein performs transportation services for the health and / or social service organization(s) listed herein and

works solely as a medical provider vehicle, as defined by §200.01.q of the Westchester County Taxi & Limousine Commission

Rules and Regulations. It is understood that operating as a for-hire vehicle after being granted a WCTLC Medical Provider Waiver

shall result in fines and revocation of said waiver.

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 affirm under penalty of perjury, 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

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

State of New York

)

County of ____________))ss:

________________________________________

Notary Public Signature

WCPD322 (Rev 09/2016)

Page 2 of 4

Form Wcpd322 - Medical Provider Waiver Application - Westchester County Taxi & Limousine Commission Page 2

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