HomeMy WebLinkAbout15-043 IDENTIFICATION NO. IS- - CD 4 ,S
• ' i` r 1 (Office Use Only)
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CITY OF IOWA CITY APPLICATION FOR TAXICAB/MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m.to 3 p.m.,Monday—Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the"required"information will result in denial of the application
(319) 356-5040
(319) 356-S497 FAX
IrstMid le / Last
1. Name(REQUIRED) e, i-e K. E arri e I-0, crrcrPP
2. Address(REQUIRED) 'f J 41 Spp+uee
3. Contact Information (REQUIRED) Email: 1f 4 . . . _s ,. -II Phone: (.. J 736'tiOg'q
(All w itten communication sent v'- email)
4a. Chauffeur's License expiration date (REQUIRED) V2/6 A.0,7
b.Taxicab Business Name(REQUIRED) Pji K n5 TRxl
5. Prior experience in transportation of passengers: (116 e-Ir t v e r 43'./7 9 7'e-1 ear reg►
Systems 6'1141/'0�.tj-4 ii eerT-nc_rt' A,orge I 8g6 "--/c7 0
Soccer wtowt- likka ,s cias/cis If cc wa c.
6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? go
Type of offense Where When
What happened to the charge?(Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other 7`
7. Have you been arrested/charged with any traffic offenses in the last five years? NG ,
ry
Type of offense Where When "----1
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? No
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes,please provide the name(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION(DCI)REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report(form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
'Page 2
I hereby certify,that I have issued to me by the Iowa Dep rt ent of Transportation val. Chauffeur's license number
6 36 p1, os- issued on of/2j(3 expiring on 3 . I understand that if I
falsely answer any questions in this application, that this ap lication maybe denied. I re that in makingthis application, I
9 PP
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to this application, and I further agree that, if authorization to be a taxicab driver is granted,to comply at all
times with all of the provisi s itle 5, Chap r of the Ci' Code. (Needs to be signed in front of a Notary Public)
RtSignature of Applican j . '' Date ›/>.6-A5.
STATE OF IOWA
COUNTY OF JOHNSON ) /
scribed and sworn to before me by /�e /e. reday
. w �� on this of
�/S
t KEII_IE K.
-Tuber
'491-A, mmis-'''"11.Imber 22r 819
t9 - m,,;-10 Exp Notary Public in and for the State of Iowa
************************************************************************************************************************************************
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City(Title 5,Chapter 2,City Code).
;ow// %( l
Signatu - • r•Tr!►" ief or designee ate
AFTE- • 'PROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR.
, A 4" q,26 /s
Signat of City Clerk or designee ate
J
Office Use Only _
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Approved application
DCI report
State certified driving record '
Website update
Clerk/TAXIDRIVBADGEAPPL92014amended.DOC 02/2015
Feb. 23. 2015 1 :51PM Div of Criminal Investigation DCI IoteNo. 1522 P. 3/9�os
02/g0/2015 11:06 FAL (OT 1
3.1
STATE OF IOWA .• 0
Criminal History Record Check M
Request Form •
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- DCI A000unt Number: X1383-FG
• (If i Iio.ble)
'To: Iowa Woke of Criminal IgveN181tpoe
kraal IAA r6e aX t
_ Support°paratlane Surma,r Floor • g,��vu,,, (�r,
2151E 7•Street
Deb Moines,tows.10319 OtawC , LA 5a34 0
(515)72S•d066 �+ �
(sly)725.4*.)Fa: •
• Phonei t 3IA 3 twill-
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y{
. Fut 71311 561"%;141 -
I am reaueating an Xowb Crlltlitiai Iieoor rd. Chock on: • _ - ___---
Last Name . . First Name • Middle Name
•
LW.la '
Date of Birth( M Gender Crr1 Rodd Security Numbert =�
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. w rinds i Ferasaie / •- . '~.;
ot
Waiver Info ,, ,n:Without a Biped waver from the Subject of the ra,a complete
Mud,'tioa,as historyllowed mobm
aMtn e
be releasable,per Code of Imre,Chapter mss.Amfi 04
•obtain,0 waiver signature from lbs subject of the ..:i t.
Waiver Release th•obfova 1irmi+o►oir017. , wInveuMl�eeowie"dBecodaiming►aimlimymoordcheckw1*d+DivisionorAfr id .
IoweiNlha(DM tie aiming Inns deli oopore / M by Yr DQ nrY rotaaed d by law.
Iow4 Cftoil lord Ch e R Its (Da mgwily)
As of 1-23-45 a acarol)of the provided name and date of birth revealed: . r
Itt No Iowa Criminal History Record found with DCI , - '
0 Iowa Criminal History Rocord attached,DO#_
' J
DCI initials - "
DCI-77(08125110) •
Received Time Feb, 20, 2015 11 :00AM No. 1392
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