HomeMy WebLinkAbout14-123Authorization Number 4 1
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CIN OF IOWA CIN APPLICATION FOR T I/MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made
410 East Washington Street between 8 a.m. to 3 p.., Monday,- Friday.)
Iowa City, Iowa S2240-1826
(319) 356-5040
(319) 356-5497 FAX
IFirst Middle V..ast.
dad...
2. MalhngAddve .. ( .......
3. "telephone: Horne G)tirer.....
4. Prior experience in transportailon of passengers:.
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? A/ U
6. Have you been Wrivicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?_AJL.,'
7. Have you been convicted of any traffic offenses in the last five years?
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8. Has your drivel's license or chauffeurs license been suspended or revoked in the last five years?—,44V—
Type
ears' V
Tyne of offense
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
°bado 0312014
I hereoy certifv that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
`'� y Z 2'.
1 understand that if i falsely answer any questions in this application, that this
applicati n may be denied. I understand that if I falsely answer any of the questions in this application, that this application will
be denied. 1 agree that in making this application, 1 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. (Needs to be signed in front
of a Notary Fub11c)
Signature of Applicant Date C>�
YOU ARE NOT VALID TO DRIVE°JATAXI Ifi IOWA CITY UNTIL AUTHORIZA7 N DECEIVED 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
o �
u t.. � ..... _. On this '"""" day of
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).
lyl1
Dat
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.
Signatu a of City Clerk or designee^�
..............................................................................................
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/z" (width) and 5'/z"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
c•eddte)dddnbdgeapp2014.dop 03/2014
May. 19, 2014- 11:48AM Div of Criminal Invest gat onNw' 0348 P•, •?oz�aoa
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'Foh Gowvta DhVl 'hon or Crhnhnat Investtgatton From: Yellow Cah LLL Ci
Support Oparatllons g ureaat l" Floor '0 BOX 423 .
SAS 2e 71" Street,
tDas Moines, Iowa 3931P Iowa C6ay� IA, 52244
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axrrar Fp(�aasdapay vert,' wiphaao$t a atanad waiver from the euhteat aD the regtua®t a mrumtptete grirmtmat history record may not
retleasabhh per Cod* of lowap Chapter 692.2„:For OMppeke erpmnhmah hhztary reaard Werunathen, ae allowed WPM atwrays
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As of �� - � a search of the ,provided mama and date of birth revealed.
No Iowa Criminal. History R000rd found with DCI
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Iowa Criminal History R.aeord attached, BCS
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Received Time May. 14. 2014 I1:OOAM No. 6548y.........
Cllty/State:
Iowa
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5115-:2,41-9 -24
KIM- 515 Z39 183'ir
5/15/2014
Bickford George
Frederick IV
401 9TH AVE
WELLMAN, IA
523569338
Mailing WELLMAN, IA
City/State: 523560296
irti' ed Abstract of IC,mlr villirn Record
DL/ID #:
700AJO627 (IA)
Customer #:
6101512
Class:
D
ID Status:
None
Audit #:
7011629
DL Status:
VAL
Issue Date:
06/06/2013
CDL Status:
None
IExlpilratllon Dates
01/15/2018
CIDII. Cert Status:
None
IEndorsemeutse
3
CIDL Mod Stature::
None
Restrictions:
NONE
Restriction
None
SUIPIplemaent:
Date of Birth:
1/15/1967
Sex:
M
IHlistalry ,QII' fo rmatTion
Name: Bickford, George Frederick IV Dill 700AI0627
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of
an official record currently in the custody of said Office, and that I have been authorized by the Director 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:
5/15/2014
97fM �° i
„ V
C I
ZIP
WOffice of Driver Services
Iowa Department of Transporation
Name: Bickford, George Frederick IV Dl./IID: 7000..'10627