City of Cumming Police Department

Transcription

1 Application for Certificate of Public Convenience Vehicles for Hire Instructions: Every question shall be fully answered. If the space provided is not sufficient, then continue the answer on a separate page. Be sure to refer to the question number and letter on the attachment. When the application is complete, then the application and all supporting documentation must be dated, signed and sworn before a notary public. License Year SECTION A Business Information Business Name Applicant Name Business Address Business Telephone Federal Employer ID Number or Social Security Number Mailing Address, if different from above

2 SECTION B Type of Ownership (Check One) o Individual o Partnership o Owner with investors o Corporation with one location o Corporation with multiple locations in Georgia o Interstate corporation SECTION C Parties Having any Direct or Indirect Interest in the Business and/or in this Application Name Address Date of Birth Description of Association * * * Name Address Date of Birth Description of Association

3 Name Address Date of Birth Description of Association * * * Name Address Date of Birth Description of Association SECTION D How much of the capital of this business is borrowed? Amount and Terms From Whom (institution or individual)? Name Address

4 SECTION C Company Manager Name Address Date of Birth Sex Telephone SECTION D Applicant Questionnaire Name Date of Birth Race Sex Height Weight Hair Color Eyes Address County of Residence Length of Time at this Residence Home Telephone Cell Phone Place of Birth Country Occupation Employer Driver s License Number State

5 Employment History 1) Employer Job Description Dates Employed Supervisor/Telephone Location 2) Employer Job Description Dates Employed Supervisor/Telephone Location 3) Employer Job Description Dates Employed Supervisor/Telephone Location

6 4) Employer Job Description Dates Employed Supervisor/Telephone Location Residence History 1) Address Dates of Residence 2) Address Dates of Residence 3) Address Dates of Residence 4) Address Dates of Residence Criminal History List all convictions, guilty or nolo pleas for crimes. 1) Offense

7 Date Location Disposition 2) Offense Date Location Disposition 3) Offense Date Location Disposition 4) Offense Date Location Disposition 5) Offense Date Location Disposition 6) Offense Date Location Disposition

8 Driver s History You must obtain an official driver s history from the DMVS and submit it as an attachment to this application. The application will not be processed without this item! SECTION E Miscellaneous 1) Prior Applications Has any person with an interest in this application made application at any previous time for a vehicle for hire license? Yes No 2) Prior Criminal Convictions Has any person with an interest in this application ever been convicted of a crime, other than a minor traffic violation? Yes No If yes, explain

9 3) Previous Revocations or Suspensions Has any previous license been issued to you or a person with an interest in this application been revoked or suspended or revoked by any state, county or municipality? Yes No If yes, explain 4) Other Vehicle For Hire Interests List all other vehicle for hire businesses with which you or any person having an interest in this application have any association. Business Name Address Telephone Nature of Association

10 Business Name Address Telephone Nature of Association 5) Unpaid Judgments Business Name Address Telephone Nature of Association List and explain all unpaid judgments against any person having an interest in this business.

11 6) Insurance Please attach a copy of your insurance policy showing the required amount of insurance according to Article VIII of Chapter 22 of the City of Cumming Ordinances. 7) Company Insignia Attach a schematic or photograph of your design for the vehicles for hire used by you company. SECTION F Business Practices and Employees Vehicle Ownership Company Owned Company Leased Driver Owned Employees Provide a list of all drivers. Note that this list does not substitute for a driver permit issued by the City. Also provide a list of support staff (non-drivers). Business Hours Please list the hours of service (i.e. 24 hours a day, nine to five etc), business office hours and any applicable regularly scheduled holidays.

12 Equipment List all associated equipment, including taximeters (if used), radios, Nextel etc. that is used in the standard conduct of business. SECTION G Certification This section should be notarized, signed and dated. I hereby certify that all information contained herein is true and accurate, that I have received a copy of the vehicle for hire ordinance and that I am aware, as the licensee, that I may be held responsible for employee conduct regarding all licensing, insurance and Ordinance requirements during their operation under the auspices of this license. I further understand that any changes to the information contained herein require timely notification of the Cumming Police Department and the. Signature of Applicant Date Sworn and Subscribed Before Me This Day of,. Notary Signature