HomeMy WebLinkAbout14-2661 F i
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
Authorization Number —
(Office Use Only)
APPLICATION FOR TAXI I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday.)
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Middle
3. Contact Information (REQUI RED) Email:
E .
t Prior experience in transportationof passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?/.
Where
M
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?-4'�Q—
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
8. Has your drivers license or chauffeurs license been suspended or revoked in the last five years? &P
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
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE GETIFI
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHI9F"REV IEW
You must apply for an individual Department of Criminal Investigation Report (form available upon r6quest).„
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
09/2014
I hereb certify that I have is ued to me by the Iowa Department of Transportation a valid Chauffeur's license number
3 Q i . I understand that if I falsely answer any questions in this application, that this
application ma 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 pr9visions of Title 5, Chapter 2, of the City Code. (Needs to be signed rn frcnt
of a Notary Public)
Signature of App,ljp5 ., Date
r
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERKS OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed eannd sworn to before me by On this day of
.-
Public in did for the State
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).
Q2,!
SignatureApfP Ike ef.ac.designee Date
YOU ARIE-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
Signa of City Clerk or designee
�_./�L / /�
ate
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 5'/i'
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ciarwrAXIDR BADGEAPPLe2014ameridedDoc 09/2014
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IOWA CITY, IA
522402216
Mailing Address: 16 ANISTON ST
t"eit.11 nee Abstract DSP Driving Record
DL/ID 617XX3816 (IA)
Class: A
Audit #: 7169570
Issue Date: 07/25/2013
Expiration 06/21/2018
Data:
Endorsements: NT
IltestricUons: NONE
Date of Birth: 6/21/1972
Sem M
Customer #:
2345972
ID Statua:
None
DL Statusa
VAL
CDL Status:
VAL
CDL Cart
Excepted Interstate
statues
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CDL Med
None
Statues
Restriction
None
Supplement:
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Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of'TPansportatlon, do
hereby certify that I am the custodian of the retards held by the Office of Driver Services, that this is a tme and'accuratucopy of
an official record currently in the custody of said office, and that I have been authorized by the DirectpS of the Iowa Department of
Transportation 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: "
IOWA
4: ( I'
Dec. 1, 2014 2:34PM Div of Criminal Investigation No,5244 P. 505
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^z;RTATE OF IOWA
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