Form Tnc-1 - Transportation Network Company License Application
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1
2TRANSPORTATION NETWORK COMPANY LICENSE APPLICATION
RIDESHARE UNIT, PO Box 2603, Albany NY, 12220-0603
DMV OFFICE USE ONLY
CHECK THE BOX THAT APPLIES:
¨
APPROVED
¨
Date Issued:
Initial License Application
¨
Permit Number:
• Complete sections 1, 2 and 3.
DENIED
• Sign the certification in section 4.
Expiration Date:
• Attach a sample of your trade dress/company insignia that will be placed in vehicles.
• Attach a sample of your TNC driver permit without personal driver data.
• Attach a copy of your Group Insurance Policy and the Certificate for your Group Insurance Policy (ex. Form ACORD 25)
listing NYS Department of Motor Vehicles as the holder of the Certificate. If you have more than one policy, provide a copy
for each policy and the Certificate.
• Attach a copy of proof of authorization to do business in NYS issued by the Secretary of State.
• Pay the $100,000 initial application fee (certified or bank check only). If the application is denied, DMV will keep $10,000.
¨
Renew License
• Complete sections 1, 2 and 3.
• Sign the certification in section 4.
• Attach a copy of your Group Insurance Policy and the Certificate for your Group Insurance Policy (ex. Form ACORD 25)
listing NYS Department of Motor Vehicles as the holder of the Certificate. If you have more than one policy, provide a copy
for each policy and the Certificate.
• Attach a copy of the proof of authorization to do business in NYS if your business name has changed since your initial application.
• Pay the $60,000 annual renewal fee (certified or bank check only). If the application is denied, DMV will keep $10,000.
¨
Update Information Only (no fee required)
• Complete the appropriate section of this form to indicate any change in information you previously provided.
• If your Group Insurance Policy changes, attach a copy of your new policy and Certificate.
• Sign the certification in section 3.
Send a certified or bank check payable to the “
” and your application to:
Commissioner of Motor Vehicles
.
NYS Department of Motor Vehicles, Rideshare Unit, PO Box 2603, Albany NY 12220-0603
THIS APPLICATION WILL BE RETURNED TO YOU IF IT IS INCOMPLETE
SECTION 1: COMPANY INFORMATION
Transportation Network Company’s Legal Name
Mailing Address
City
State
Zip Code
County
Telephone Number
Fax Number
ext.
(
)
(
)
Physical Address (if different from mailing address)
City
State
Zip Code
County
Website or web address homepage
SECTION 2: CONTACT INFORMATION
(TNC correspondence will be sent to the person listed)
Contact Name
Title
Mailing Address
City
State
Zip Code
County
Business Telephone Number
Fax Number
Email address
(
)
ext.
(
)
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TNC-1 (6/17)
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