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Please list 4 City of SOUTH BEND (NOT COUNTY) Residents who have known you at least 5 years: <br />Name Full Address City, State, Zip Telephone Number <br />NOTE: A records check will be performed by the South Bend Police Department. Failure to answer <br />questions below completely and truthfully will be grounds for this application to be rejected. <br />Have you had experience in transporting passengers as a driver or chauffeur? <br />Yes __ No __ (If yes, specify company and length of employment) ____________ _ <br />Have you ever been convicted of a Felony within the last 20 years? <br />Yes __ No __ (If yes, specify date and circumstances) ________________ _ <br />Have you ever been convicted of a misdemeanor within the last 10 years? <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 applying for or 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 />PLEASE NOTE: <br />Applicants must supply a certificate from a licensed physician certifying that the applicant does not suffer <br />such disease or infirmity which may make him/her an unsafe or unsatisfactory driver. All applicants shall <br />furnish (2) passport size photograph of him/her to the Department of Community Investment who shall <br />affix that photograph to the license. This license shall be posted in full view of all passengers in the <br />taxicab. All applicants must have a valid Indiana Public Passenger Chauffeurs License or a For-Hire <br />Endorsement.