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2. Please complete the application below. All fields are required. Any application not fully completed may be rejected and returned for proper completion. Should any answer(s) require additional space, continue on the text box at the bottom of the application.

   An approved permit is $50. The renewal fee is $25. All permits expire on June 30 in the second calendar year after issuance.
4. 
   
6. Applicant Information
8. Last Name:*
10. First Name:*
12. Middle Name:
14. Maiden Name/Other Names Used/Nicknames:
16. Current Mailing Address:*
18. City:*
20. State:*
22. Zip Code:*
24. Home telephone number:*
26. Home e-mail address:*
28. Cell telephone number:
30. Home fax number
32. Work telephone number:
34. Work e-mail address:
36. Work fax number:
38. Current Employer’s Name & Address (if employed by other than a taxicab company):
40. Social Security Number:*
42. Race:*
44. Sex:*
46. Date of Birth:*
48. Place of Birth & Nation of Citizenship:*
50. Height:*
52. Weight:*
54. Hair:*
56. Eyes:*
58. 
    
60. Addresses for the past 2 years (Street address, city, state, ZIP Code)
62. Address 1:*
63. From:*
64. To:*
66. Address 2:
67. From:
68. To:
70. Address 3:
71. From:
72. To:
74. 
    
76. Criminal History
78. Have you ever been convicted of any crime(s) (including DWI, DUI, etc.)*

    1. Yes
    2. No
80. 
    
82. If Yes, explain what charges, when they were, and the sentence you received:
84. 
    
86. Have you ever been on supervised probation or parole:*

    1. Yes
    2. No
88. 
    
90. If Yes, describe when and why you were or are on probation or parole, and the name of your agent:
92. 
    
94. Have you ever been on unsupervised probation, or received Probation Before Judgment (PBJ):*

    1. Yes
    2. No
96. 
    
98. If yes, explain when and why you were or are on probation.
100. 
     
102. License Information
104. Current driver’s license number:*
105. State:*
106. Expiration Date:*
108. 
     
110. Have you had a driver’s license in any other state or country in the last 10 years?*

     1. Yes
     2. No
112. 
     
114. If Yes, list where:
116. 
     
118. Has your driver’s license or privilege to drive a motor vehicle ever been revoked, suspended, cancelled, or refused anywhere?*

     1. Yes
     2. No
120. 
     
122. If Yes, list each time and explain why.
124. 
     
126. Employment History
128. Employment for the past 2 years, beginning with the most recent and including any periods of unemployment:
130. Employer 1:*
131. Address 1:*
132. From:*
133. To:*
135. Final Position:*
137. Employer 2:
138. Address 2:
139. From:
140. To:
142. Final Position:
144. Employer 3:
145. Address 3:
146. From:
147. To:
149. Final Position:
151. 
     
153. Alcohol and Drug Use
155. Do you drink alcoholic beverages?*

     1. Yes
     2. No
157. 
     
159. If yes, describe how often and how much you drink:
161. 
     
163. Have you used illegal drugs within the last 2 years?*

     1. Yes
     2. No
165. 
     
167. If yes, describe what drugs, when and how often you used:
169. In order to receive Phase 1 (preliminary) approval, you must bring with this application:

     1. Certified copy of your full driving record from the state where you are currently licensed;
     2. Certified driving records from all states where you have been licensed to operate a motor vehicle in the last ten years;
     3. A check, money order, or exact cash in the amount of $10.00 payable to The City of Frederick;
     4. A photocopy of your driver’s license;
     5. If not a US citizen, a copy of your Employment Authorization Card issued by the United States Department of Homeland Security.
     6. A check or money order (please call them to check on fee amount) payable to Frederick County Sheriff’s Office to be fingerprinted
     7. OR a full criminal history report , MD and FBI, issued by the Director of the Maryland Criminal Justice Information System (CJIS) that is dated no more than 2 weeks before you apply.
171. 
     
173. If your application and background check pass Phase 1 (preliminary) approval, you will be notified in writing to submit the following documents within 15 days of that notice. You may, but are not required to, submit them at the same time as the documents listed above.

     1. A statement from a licensed medical professional certifying physical fitness to operate a taxicab;
     2. Proof that you have passed screening for illegal drugs from a State-certified laboratory not more than 15 days prior to application.
175. 
     
177. 
     

179. I solemnly swear or affirm, under penalty of perjury, that the information I have provided in this Taxicab Driver’s License Application is truthful and complete. I am aware that, should the investigation of the facts contained in this application reveal any willful misstatement or omission of material fact on the application, it will be rejected and I will receive no further consideration for the position for which I am applying.

     I am also aware that, as a Taxicab Driver licensed by The City of Frederick, I am subject to random drug testing under the authority of The Code of The City of Frederick, Chapter 23.

     Your full name will be used in lieu of a signature*
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181. 1. Receive an email copy of this form.
182. Email address

     This field is not part of the form submission.

183. Submit

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