Surrender Form - Nyc Department Of Consumer Affairs printable pdf download

Surrender Form - Nyc Department Of Consumer Affairs

42 Broadway

SURRENDER FORM

5th Floor

New York, NY 10004

If you currently hold a Horse Drawn Cab license issued by the Department of Consumer

Dial 311

Affairs (DCA) and would like to surrender it for a refund and/or request a transfer of your

(212-NEW-YORK)

license to another individual/business, please complete the form below and attach your

original license document.

nyc.gov/consumers

Business Name:

Business Address:

DCA License Issued Date:

DCA License Number:

CAMIS Number:

DCA License Plate Number:

Why are you surrendering your

license?

Will you be vacating the

YES

premises?

If known, please provide the

name of the new occupants and

their business type.

Mailing address where a

refund will be sent if you

qualify.

I understand that continued operation without a license may subject me to civil and/or

criminal penalties. In addition, I understand that falsification of any statement made herein

is an offense punishable by a fine or imprisonment or both.

_______________________________

___________________________

Signature

Print Name

_______________________________

___________________________

Title (if any)

Date

Surrender Form - Nyc Department Of Consumer Affairs