Taxi / Livery Permit - Fee - $10

First Name

Last Name

Address

City State

Zip Code

Age 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90

Date of Birth - Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sex Male Female

Height 4-0 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 4-10 4-11 5-0 5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10 5-11 6-0 6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 7-0 7-1 7-2 7-3 7-4 7-5 7-6 Weight

Hair Color Blonde Brown Black White Red Eye Color Green Blue Brown Hazel Black Complexion Albino Pale Fair White Light Tan Dark Tan Brown

U.S. Citizen? Yes No Please select.

Passport #

Alien Card# (if applicable)

School Attended & Years

Social Security #

Occupation

City State

Zip Code

Have you ever been arrested? Yes No -- Please select an item.

If Yes, Explain.

Certification I hereby Certify that all of the information included herein, provided by me is true.

I am aware that if any of the information provided by me herein is willfully false, I am subject to punishment.

FALSIFICATION OF ANY INFORMATION WILL RESULT IN CRIMINAL CHARGES!

N.J. STATE STATUTE 2C:21-3(B)

E-mail Phone #