Taxi Driver Application - Carbondale, IL

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Have you ever been charged with driving under the influence (of alcohol or drugs) and/or reckless driving? ___ yes ___ no If yes, please list the date(s), charge(s) and disposition(s) of said violations (attach additional page(s) if necessary) ________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Other than the charges of driving under the influence and/or reckless driving, have you received or been charged with any other types of moving violations in the last five (5) years? ___ yes ___ no If yes, please list the date(s), charge(s) and disposition(s) of said violations (attach additional page(s) if necessary): _____________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ List address of every place you have resided within the last three (3) years (attach additional page(s) ifnecessary):______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ List name and address of all employers within the last ten (10) years and the name of your immediate supervisor during such employment (attach additional page(s) if necessary: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
List any and all information pertaining to your criminal history, including date(s) of arrest(s), location(s) of arrest(s), specific charge(s) filed and disposition of all charge(s). Attach additional page(s) if necessary. NOTE: FAILURE TO COMPLETE THIS SECTION COMPLETELY AND ACCURATELY COULD RESULT IN AUTOMATIC DENIAL OF YOUR LICENSE. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Attach to this application: U Copy of driver's license (License must reflect current address before taxi driver license is issued!) U $60 fee for criminal history check. Checks may be made payable to City of Carbondale. *** Although there is no license fee, applicants must pay the fee for the Illinois criminal history check, which costs $60. This fee will be more if the criminal history must be checked for states other than Illinois. The applicant will be required to pay all costs for the criminal history check. U Criminal History Release form (back page of application). APPLICANT AUTHORIZATION AND CERTIFICATION By my signature below, I hereby authorize the City of Carbondale, its agents and employees, to seek information and conduct an investigation into the truth of the statements set forth in this application and accompanying documents. I further request M.B.I. Worldwide to release any and all information pertaining to my criminal history to the City of Carbondale City Clerk and City Manager for the purpose of consideration of this application. Under penalty of perjury, I hereby certify that the foregoing and accompanying information contained in this application is true and correct. I also acknowledge receipt of the Carbondale City Code governing the operation of taxicabs and agree to abide by all of those regulations. Further, I agree to immediately notify the City Clerk of any changes to this application and/or my driving record as required by the City Code. _____________________ Dated _____________________________ Applicant's Signature Subscribed and sworn to before me this _____ day of , . _________________________________ Notary Public Please submit fee of $60 payable to ACity of Carbondale@. Additional fees may be required for out-of-state inquiries, assumed names and a/k/a or maiden names. Additional fees must be paid upon demand. Failure to pay additional fees may result in suspension or revocation of your taxicab driver=s license.
Page 1: CITY OF CARBONDALE, ILLINOIS APPLIC
Page 5 and 6: I acknowledge I have been provided
Page 7: States may enforce the FCRA, and ma

Taxi Driver Application - Carbondale, IL

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