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HomeMy WebLinkAbout15-022t ►Bolt ®1 tw CITY OF IOWA CITY 410 East Washington Street Iowa CRS Iowa 52240-1826 , (3 19) 35 C5431 -FAX 1. Name(REQUIRED) FAR -Mm", I� Authorization Number (Office Use Only) APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) FaMure to crarrt�dete tdag "rendez=d" so�fCprrrBadon will result do denial of the g. .11c Middle Last 2. Mailing Address (REQUIRED) 3. Contact Information (REQUIRED) Email: 42 .5jie, P °3e..h2 A, FV&.L'W Cell Phone: 21,9' 9d`µ .f 4. Prior experience in transportation of passengers: y e? gait/ 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where �w 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense Where 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A)6 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 ndtile(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CE1k'hFIED1 DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHMF'REVk* You must apply for an Individual Department of Criminal Investigation Report (form available upon request). ,` (OVER FOR REQUIRED SIGNATURE AND NOTARY) C q I her y certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number 1hf 111115 t . I understand that if I falsely answer any questions in this application, that this application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will be denied. I agree that in making this application, I 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 a license is granted, to comply at all times with all of the provisions of Title 5, Chapter 2, of the City Code. ([tlseds to be signed in frcint of a Notary Public) Signature ofApplicarlt '- Date J r YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by On this ;79 � -qO day of 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). Signa re of Mlide ehf or dLdsignee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. Signature of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8%" (width) and 5 %11 (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update CW&TAXIDRPAMGFAPPL92014amwded.DOC 09/2014 al"AW MT humi, >i DO "acRtuu�s of f Na'6v8sce' 8s:rrrica a PO a:iarat IX204 €? 2 .. ', iMs ^i0Yarc 92M Phrag,e:115-2444124 g.00O-S32-11121rfax 5,15..230-1837 WWW'Wwadot.gDY City/State; 1/15/2015 Collins, Anthony 1602 YEWELL ST IOWA CITY, IA 522406000 Nailing Address; 1602 YEWELL ST s :� arra... Rw' taf din 11,3utte 10/01/2011 Celrtrffied Arlstra Rt. of (Driving ReCord Name: Collins, Anthony DL/ID: 288AES480 DL/ID,##® 268AE5480 (IA) Customer S. 5342369 Class: _ 0 ID Status: None Audit #: 8644200 DL Status: VAL Issue Dat®. 11/25/2Q34 CDL Statusa None Expiration 12/05/2020" CDL Cart None Dated Status: Endomementm 3 CDL Ned None Status: Restrictions: NONE Restriction None Date of Birthz 12/5/1972 Supplement - Sam M CID , f, under in .35 515 �ILtr� += M 11 4 w L + F.. Y 51 ^,. ITransportation to so certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: r .� Q 1/15/2015 tee•' WE MIA -'e`a� tail' Office of Driver Services on Iowa Department of Transportation Jan, 16. 2015 3:20Ptatl Div of Criminal Investigation V 4 11. 1j. L V 1 .) J. -Tun[, V I l) V I C I& y I{ r V I I u w 6 b I t y 1'tlF15 A j1 r 'q�G `1 (]�i,�rIli History i�°r't�.],VY4D Check STATE� , . � � 1r D471�Request Form Tw lowa DIV92101Ao� vB�c6ln�p na dd��&dawn Support O door 2:9.$ a 70sda- t Opa madnneoa a'oava .50319 (515) 72~&6066 ('.515)77-5-6000 Un aaa :I waa d rduaa¢mka9 HiAmw Record Rlaat No, 8263 P. 2/4 11019774 r. t Das''.AcccnnaA.ff4.@-dba4"Y,,,,,YIL q r" '�...... Qga'appGv"catlike} From d�d¢Yr ad"Yaava �db� (City clerda9a Oface CIO F.. �omb aft"t lor�.U $2240 - - Phonal 3.19-396^5041 Yam R9-s9im-R99 WaroorInf6rone Y Without wk A wwea wwagvar A°amm the subject d &a rrogkkaak a oawwkpgede cadkadkkad andadory ireeard unnmyn wood he rehoatakkle, per Conde offawmw Cduapfer 6.92.2.IRoY lark pjg�g argimnquaad dudsdory &®eard gkDaormnaddmavm am agll®baa Yroyr Vamr, m&vAq.v PI'aiver.Release.. damttayghon Im DawonRdF,ahYoaQq�Ig„ Aayacegandlnaklhbkdrey MM d ra conduct an Yawl crInckmd h1goryaccurd a4wkbwBme ft Dhvdalon u[cldn nan myhlhaVDV)NumayYGoirekeneoagmmwlYawn©aPryVmw- ,q � Aa o..f.._._._._._._.. � � �_ a a ,oa°cda afflop rovkded nomo and date o£birth amveale& towa. C wna,9 Histo:ryRecord attached, DCI # e y �aa I ldaf¢dala,_._._._. Received Time—Jan. 4:43A -No, 8854 -------------- nrT_��rnai %t(, r., Jan.16. 2015 3:20PM Div of Criminal Investigat on :IOWA CR:IKERAL RZSTORY DCI 00915409 NON CONVICTION PAGE I OF 1 DATE PRINTED - 2015/O1/16 DCI;00916+�0"� NAME - COLLINS, HO DOB SEK 'RAC HGT WGT EYE HAIR SKN POB 19721205 M B 605 200 ERO BLK DRK IL ADDITIONAL IDENTIFIERS PHOTO A,VA.T.La4n1,E Y CC{ RECORD **'* AGENCY: TA0520100 CORALVILLE PD CHARGE NO— 01 Y.A. STATUTE IA700.2A(2) (B) )DOMESTIC TIC ABUSE ASSAULT CAUSE BODILY INJURY) NTL I1f:4'MSS TRK#e 1AOOAOU01 COURT DISPOSITION AGENCY.: IA052019J JOHNSON CO DIST COURT COUNT NO— 01 XA STATUTE IA700,2A(2)(B) DOMESTIC ABUSE ASSAULT CAUSE BODILY INJURY/MSUTL ILLNSS(SRMS COURT CASE IDe 06521 SRCRO92609 CHARGE CIASSe NON CONVICTION TRK#: 1A00AOU01 SENTENCE DISP EFF DAT DEFERRED JUDGEMENT $315 CIVIL PENALTY 2017.0330 PROBATION 1Y 20110330 SUPERVISED PROBATION TO DCS DISCHARGED FROM 20111110 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD MAINTAINED gY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD 13UT CAN ONLY BE RRuASED TO NON—LAW ENFORCEMENT A09NCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION No. 8263 P. 3/4