La Driver Permit Application
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1
2CITY OF LOS ANGELES
DEPARTMENT OF TRANSPORTATION
DRIVER/ATTENDANT PERMIT APPLICATION
New
Permit No.______________
(Assigned by LADOT)
Renewal
Replacement
(213) 928-9600
Company________________________________
Ambulance
Litter Van
Non-Ambulatory
(Print in Ink)
1.
Taxicab
Motor Bus
PTV
Other
APPLICATION FOR
DRIVER PERMIT
ATTENDANT PERMIT
2.
Name____________________________________________________________________________ 3. SSN________ -_______-__________
(Last)
(First)
(Middle)
Federal Law (P.L. 93-579. Sec. 7) requires that you be informed, when asked for your Social Security Number, that this number must be provided for identification purposes in the process of issuing Driver Permits and Attendant Permits.
Authority requiring this informing is based upon provisions of the Municipal Code and the Rules of the Board of Transportation Commissioners, which were operational prior to January 1, 1975.
4.
Home Address_____________________________________________________________________________________________________
(Address)
(Apt. #)
(City)
(Zip Code)
5.
Mailing Address____________________________________________________________________________________________________
(if different from above)
(Address)
(Apt. #)
(City)
(Zip Code)
Home /Cell Phone(_____) _______ - _________ Work Phone(_____) _______ - _________ E-Mail_______________________________
6.
Age_____ Birth Date_____/_____/_____ Birthplace_______________________________________________________________________
7.
(City)
(U.S. State or Country)
8.
Height______ft.______in. Hair Color______ Eye Color______ Weight______ Race/Ethnicity:___________ Sex:
Male
Female
Questions regarding race or ethnicity and sex are asked for Affirmative Action research only
and will not affect a permit in any way.
9.
Have you ever had a Driver License or chauffeur license suspended or revoked?
Yes
No If yes, explain on the reverse side.
Yes
No If yes, explain on the reverse side.
10. Do you use intoxicating liquors and/or addictive drugs?
11. Do you have any mental or physical incapacity or infirmity?
Yes
No If yes, explain on the reverse side.
12. Applicant must present the following valid, original documents. Provide the expiration date, if applicable, for each required document.
Ambulance Driver / Ambulance Attendant/
Non-Ambulatory Driver /
Motor Bus Driver /
Taxi Driver
Litter Van Driver / Litter Van Attendant
Non-Ambulatory Attendant
PTV Driver
CDL No.*______________________
CDL No.*________________
CDL No.*______________
CDL No.*_____________
exp. ____/____/_____
exp. ____/____/____
exp. _____/_____/_____
exp. _____/_____/_____
DMV H6 <=30 days
DMV H6 <=30 days
DMV H6 <=30 days old
DMV H6<=30 days
CA EMT-1
_____/_____/_____
CPR _____/_____/_____
Right to Work**
Right to Work**
or higher
Co. training letter
First Aid_____/_____/_____
W/C certificate
Motor Bus only: all above +
on w/c restraints and un/loading patients
if applicable
DL-51 _____/_____/_____
Right to Work**
Co. training letter
Drug Test <=30 days or
if applicable
Class “B” CDL
Right to Work**
Ambulance Driver only: all above +
For renewals only
DL-51 Med. Exam _____/_____/_____
Drug Program Certificate
Other_____/_____/_____
Ambulance Dr. Cert. _____/_____/_____
Indicating current enrollment
*CA driver license required or, for Attendant only, a CA ID Card in lieu of CDL. **Examples include Social Security Card without restrictions, US Passport, US Birth Certificate, Permanent Resident Card, Employment Authorization Card, etc.
13. Before answering the below question, read the following statement: YOU ARE REQUIRED TO DISCLOSE ALL CRIMINAL CONVICTIONS.
Failure to disclose any and all convictions, including expungements/dismissals per PC§1203.4,or the submittal of inaccurate dates of conviction
and/or expungement is falsification of application and sufficient cause for the immediate cancellation/denial of a permit and forfeiture of all fees paid .
Per PC§1203.4 you are obligated to disclose convictions, expungements, and dismissals when required by a local agency for licensure purposes.
Have you ever been convicted*, either as a juvenile, an adult, or by military
trial, of any crime (infraction, misdemeanor or felony), or entered a plea of
Yes
No
guilty or “nolo contendere” (“no contest”), or had any conviction that has
been expunged, set aside, or dismissed under CA Penal Code §1203.4?
If yes, explain on the reverse side.
*”Conviction” and “convicted” mean the final judgment on a verdict or finding of guilty, a plea of guilty or nolo contendere.
14. BY SIGNING THIS APPLICATION, I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS AND ANSWERS HEREIN ARE
TRUE AND CORRECT.
__________________________________________________________
______________________________________________
Signature of APPLICANT
Date
LADOT Clerk
Date processed
For LADOT Use Only
Taxi Exam
Criminal History / Citizenship / Tickets
Permit Status
Exam Paid_____/_____/_____
Live Scan_____/_____/_____
Approved
Conditional Approval
Exam Date_____/_____/_____
DOJ on file
Denied
see reverse side for explanation
Pass_____
Fail______
CIT (US birth cert / US passport / Nat cert) on file
Hold_____/_____/_____
DQ
No Show
PTC
Reason___________________________
Rectified____/_____/_____
DT 410 (R 7-14)
(Continued on reverse side)
Applications must be two sided with original signatures.
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