APPLICATION FOR GROUND TRANSPORTATION SERVICES PERMIT AND/OR

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