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TAXI LICENSING OFFICE USE ONLY
Applicant is applying for a:
Taxicab Vehicle License Queue Permit Courtesy PermitContract Vehicle License Queue Baggage Permit Transfer
Business Name
Name of Business Owner(s)
Physical Address City State Zip Code
Mailing Address City State Zip Code
Business phone # Fax # Email
Insurance Company Insurance Co. phone #
Make Color
Model License Plate
Year VIN
Description of signage on vehicle
Address where the vehicle is garaged or stationed Certificate of Liability Insurance attachedProof of vehicle registration attachedProof of airport inspection attached (taxicab and contract vehicle licenses only; stateinspection proof included in inspection)Proof of inspection and calibration from a licensed taximeter installation facility
I hereby certify that all statements and/or documents made in this application are true and complete, and I agree andunderstand that any misstatements of material facts herein will result in refusal of license or revocation of permit if onehas been granted to me.
_______________________________________________ _________________________Signature of Applicant Date
Date Recieved:________________ License #______________________ Issue Date:_________________License Fee Paid:______________ Permit #_______________________ Expiration Date: 7/31/2015Permit Fee Paid:_______________
CITY OF BURLINGTONAPPLICATION FOR GROUND TRANSPORTATION SERVICES PERMIT
AND/OR TAXICAB/CONTRACT VEHICLE LICENSE
APPLICANT INFORMATION
VEHICLE IDENTIFICATION
CERTIFICATION OF APPLICATION