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Date ______ _ <br />AFFIDAVIT OF APPLICANT FOR TAXICAB DRIVER'S LICENSE -RENEWAL FORM <br />Full Name ___________________________________ _ <br />(First) (Middle) (Last) <br />Present Address _________________________________ _ <br />(Number & Street) (City) (State) (Zip Code) <br />Phone Number ____________ _ <br />Age __ _ Height ___ _ Weight. ___ _ Sex __ _ Date of Birth_/_/_ <br />Driver's license # ------------- <br />(Address on license MUST match current address) <br />Have you been convicted of a Felony or Misdemeanor since your last taxicab renewal? <br />Yes __ No __ (If yes, specify date and circumstances) _______________ _ <br />Attached is a true and correct copy of my driving record from the past 10 years. <br />Signature _________________ _ <br />Attached is true and correct documentation concerning my criminal history or lack of criminal <br />history for the past 20 years. Signature ______________ _ <br />Please list the Cab Company you're employed with: ______________ _ <br />(Please notify us with any employment changes) <br />I affirm, under the penalties for perjury, that the statements herein are true to the best of my knowledge <br />and belief. I AM AWARE THAT ANY FALSE INFORMATION SHALL BE PENALIZED BY DENIAL OF THIS <br />APPLICATION. Furthermore, I have read, understand, and agree to abide by Section 4-61 of the <br />Municipal Code of the City of South Bend in the operation of taxicab service. <br />Signature Date <br />Email Address