HomeMy Public PortalAboutHackney - Livery Operator ApplicationWatertown Police Department
552 Main St.
Watertown, MA 02472
Application
FOR NEW/RENEWAL OF A HACKNEY/LIVERY/LIMOUSINE/SHUTTLE/JITNEY
OPERATOR'S LICENSE
Please check one:
New Applicant. Interested in Working for:
Renewal — Most Recent Hackney/Livery/Limousine/Shuttle/Jitney
License Number:
Employed with which Taxi/Livery/Limousine/Shuttle/Jitney
Company?
Print or Type all Requested Information:
Last Name First Name Middlc Suffix
Residential Address City State Zip Code
Home Telephone Cell Phone
Date of Birth Place of Birth
Mother's Maiden Name Father's Name
Height Weight Build Complexion Hair Color Eye Color
Social Security Number MA Driver's License Number Exp.Date
Present Employer Work Address Work Telephone
Please Answer the Following Questions Completely and Accurately
1. Are you a citizen of the United States?
If not a U.S. Citizen, a Green Card Registration Must Be Presented.
If naturalized give date, place and naturalization number
Date Place
2. Have you ever been known by another name? If so, provide name and explain:_
3. Other than Massachusetts, what other states have you resided in?
4. What is your age? You must be at least 18 years of age to apply for a Hackney/Livery License.
5. Have you ever appeared in court as a defendant for any criminal offense
(excluding non -criminal traffic offenses)?
Naturalization
6. Have you ever been convicted of any crime?
7. Have you ever been convicted of Possession with Intent to Distribute or Trafficking of a controlled
substance as defined in MA General Laws C.94c S.1?
8. Have you ever violated any law regarding weapons or ammunition for which a term
of imprisonment may be imposed?
9. Are you or have you ever been treated or confined for drug addiction or habitual drunkenness?
10. Do you have any pending charge(s) for any offense(s) against the law?
11. Has your driver's license ever been suspended or revoked?
12. Within the previous year, have you been found responsible for 3 or more traffic violations?
13. Are you or have you ever been employed by another Taxi/Livery company?
If so, please provide name and city:
If you answered "YES" to any of the questions 5-10, Provide Details Which Must Include Dates,
Circumstances and Location (Attach Separate Sheet if Necessary)
References (Name, Address and Telephone Number):
2.
3.
I declare the above facts are true and complete to the best of my knowledge and belaef. I understand
that any false answer(s) will be just cause for denial or revocation of my license to operate a 9fackney
Carriage/Livery in the Town of Watertown.
I further certify that I am not connected with any person, firm or corporation engaged in the
-Vackney/Livery vehicle business other than the employer stated herein.
Signature:
Date:
im 1N u I W KI i h itshEV w I miN LilNr:. l o be comDletea by owner of business.
The above named individual is pending employment with
Taxi/Livery Company. Signed:
Owner of Business
Business Name
Date: