HomeMy WebLinkAbout14-271Authorization number_ L —a -1 l
® 1 (Office Use Only)
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CITY OF IOWA CITY APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday.)
410 East Washington Street
10 it . lotra 52240-1826 Faflurelp,.c �rnRSAiI'e l6Pe"' u1 eC/' imFbn"8f' wll9,N;3„u�'„dJLtLnd(Inial,of!'�(%mg"d,�p,,,Pfca'll2—n
(319) 3S6-5040
(319) 356-5497 FAX
First �Fyy Middle Last
1. Name (REQUIRED)1��'�°DPxxfew °G y VKaA
2. Mailing Address (REQUIRED)
3. Contact Information (REQUIRED) Email: e �t�a cell Phone: ,.if %cwy ryyc:x
4. Prior experience in transportation of passengers: 01 a
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
e When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
Y applied City 9 e,the na
• name(s)--
DEPARTMENT
Have you ever a lied to be an Iowa Ci taxi driver using a different names If es, lease rovid W d
Y p P
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERT'IFI�D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF'AEO W
You must apply for an individual Department of Criminal Investigation Report (form avallable upon'request).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
her by certify that I h,�ayve issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
7 QA �/ PJC . I understand that if I falsely answer any questions in this application, that this
application maybe 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. (Weads to be s@gnsd in front
cf a Notary Public)
Signature of Applicant m Vie~ Date qF
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 i Cao r'lube On this day of
iiwrPm Yp(-. '2o ILA. i o r
' t
I ILtN� _ , ._� �Wu Notary Public in an or the State of Iowa
1 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 we„fare es 5ic''ee S of jbaZity of lovda City (Title 5, Charter 2, City Crede).
or
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.erg.
Signalure of City Clerk or des gnee
Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/a” (width) and 5
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ClerWrAXIDRIVBADGEAPPL92014am ded.DOC 09/2014
,lilil10ii Dec. 18. 20141 2:33PM1 Div of Criminal InvestigationY
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STATE OF IOWA
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Criminal History Rt, r d Check
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Iowa Division of Criminal JI'Vatigildon
i219 R. support714 Street
Des a..
319
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No. 6608 P. 1/5
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17CIAccount Number:
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clorlles G4krkes
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Il.oDvra q!fy 1A 52240
Phone.. ^b.19:3,re�...SO4:A
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d9am n.19"6Mi.YM1b'^149
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Waiver Jgforuakallon. MIlhonut a dgnad waiver fiirema tha subjed of $he request„ A coxnpldo ergrini xiask history r'rtaeord way not
be reRameatwfa^, perCode of Town, Chmfater 692,20 �?okLoMRIlqto eknminalIlwkotorg u°e0:ord Nuuformncadon, as aftowed by ww, , alww,ay.1
obtain a wuak:vuk skaaanfarr, fa°om the subled ® iho reataweuk'
afPJ'e'f". ,gCPffM f 1100 nr Pawrr}aranihaGon for 1110 M40wo aaekuesa6l' g rofvdwk ban wndlaed m II®M m urtni r k Batowy mcortd u cDk ueRb dAo, DivAsk'aua nfCK jPQ
dwWP.CYrfgPo�$U84 ytao Arty ePNpF6ikid r iftya dflal'.a conm M@@s ago Ihic is di dRoA,givek Pay'¢CMe%'.bY.2mt yr Ilia cP..rGUM A.0 aoQWed f'y anw,
atperAsYgnMdffddttr&
hr,kf................ aseatchoffSaoproars&dnano mdldate ofhiltkf'ovealed
No Iowa Cxvninal Mtory Record found with ACI
lowa Cs'xrnnnafl.Mstory.I2eoord a afRacheal,:IDCI #.................
Rekepved Time—Dec. 1.6.`2014— 4:,12l'It No, 6384
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