MEDICAR LICENSE APPLICATION

City of Chicago
Department of Business Affairs
and Consumer Protection
Public Vehicle Operations Division
2350 West Ogden Avenue, 1st Floor
Chicago, Illinois 60608
(312) 746-4200
(312) 746-9406(FAX)
(312) 744-1944(TTY)
www.cityofchicago.org

MEDICAR LICENSE APPLICATION

BACP ACCOUNT #:___________________________________

FULL NAME:________________________________________________________________

DATE OF BIRTH: _______________             SOCIAL SECURITY #:  ________________________________

HOME ADDRESS:____________________________________________________________________

CITY / STATE / ZIP CODE:______________________________________________________________

HOME TELEPHONE #:________________________     E -Mail Address: ___________________________

DRIVER’S LICENSE #:_______________________________   State of Issuance:_____________________

BUSINESS LOCATION INFORMATION

DOING BUSINESS AS (DBA) NAME: ________________________________________________________

BUSINESS ADDRESS:___________________________________________________________________

CITY / STATE / ZIP CODE:________________________________________________________________

BUSINESS PHONE #: ___________________________________ BUSINESS FAX ____________________

BUSINESS CONTACT NAME:______________________________________________________________

E-MAIL- ADDRESS: ____________________________________________________________________

CELL PHONE #: ________________________

PROVIDE A 24 HR. EMERGENCY CONTACT NAME:_____________________________________________

PROVIDE A 24 HR. EMERGENCY CONTACT PHONE #: __________________________________________

PROVIDE A BUSINESS MAILING ADDRESS (if different than the Business Location Address):

_______________________________________________________________________________________

IF YOU PREFER TAX MAILINGS TO BE SENT TO A DIFFERENT LOCATION, PROVIDE ADDRESS:

_______________________________________________________________________________________

 

APPLICATION QUESTIONS

Have you ever had ownership interest in any state or city license which was suspended or
revoked? Yes / No _____

Have you ever had any state or city licenses suspended or revoked? Yes / No _____

Have you been convicted of a crime within the last ten (10) years? Yes / No _____

List any pending criminal cases you are involved in. ____________________________________________________

Do you have any other Public Vehicle licenses within the City of Chicago? Yes / No _____

If yes, give the date of the suspension or revocation. _________________________

If yes, indicate the license type. _________________________

 

Have you been convicted of a crime within the last ten (10) years? Yes / No _____

List any pending criminal cases you are involved in.

Do you have any other Public Vehicle licenses within the City of Chicago? Yes / No _____

If yes, give the date of the suspension or revocation. _________________________

If yes, indicate the license type. _________________________

If yes, please write the defendant’s name. _________________________

Please indicate the type of offense, the date, city and state of conviction.

Please write the defendant’s name. _________________________

Please indicate the type of offense, the next court date, and court where pending.

If yes, list the license type(s) and license number(s). _________________________

VEHICLE INFORMATION

 

VEHICLE 1:                                                                                                                PV#______________

VIN: _______________________              Year: ___________                Make: ___________________

Model Name: ________                       Capacity: _________           Color: ________________

Vehicle Type (Circle One): Sedan   SUV    Stretch Other            State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

VEHICLE 2:                                                                              .                             PV#______________

VIN: _______________________              Year: ___________             Make: ___________________

Model Name: ________                    Capacity: _________           Color: ________________

Vehicle Type (Circle One):    Sedan SUV     Stretch    Other           State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

VEHICLE 3: PV#______________

VIN: _______________________            Year: ___________             Make: ___________________

Model Name: ________                   Capacity: _________         Color: ________________

Vehicle Type (Circle One): Sedan SUV Stretch Other State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

 

(YOU MAY DUPLICATE THIS PAGE AS NEEDED FOR ADDITIONAL VEHICLES)

INSURANCE INFORMATION

NAME OF INSURANCE AGENT :____________________________________________________

ADDRESS OF INSURANCE AGENT:_________________________________________________

PHONE NUMBER OF INSURANCE AGENT:___________________________________________

NAME OF INSURANCE COMPANY:_________________________________________________

REQUIRED DOCUMENTS

*If operating with a DBA, provide the Assumed Name Certificate from the Cook County Clerk’s Office.

*Certificate of Insurance.

*Original titles for all vehicles.

*If vehicles are purchased as Used, provide a Vehicle History Report.

*If you do not own the vehicle(s), provide the lease agreement(s).

*Original State Inspection forms for all vehicles.

*City Stickers for all vehicles.

*Provide a valid lease for the business, or proof of property ownership.

*Must complete an Indebtedness Affidavit.

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