HomeMy WebLinkAbout14-089Authorization Number_ l —
f ®(Office Use Only)
Mai
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I OF IOWA CITY APPLICATION FOR T u OTORED FEDICAS VEHICLE DRIVER
(Police Department review must be made
410 East Washington Street between 8 a.m. to 3 p.m., Monday- Friday.)
Iowa Cit 12240-1 82 6
(3!9 3S6- 0040
(31913 - 9 TAX
First Middle (Last
1. Name____ " _a. _ _
2. Mailing Address__.......gamey ^
a
3. 'T�*lephene: Ha�rne.___�7_� _ �' --a- Other:
4. Prior experience in transportation of passengers: .______........ ....... __ ___..... .
5. Have you ever been convicted of any misdemeanors and/or felonies in this state or elsewhere?
,Iypg gf offense
6. Have you been convicted of operating a motor vehicle wtlile under
years?Oj2 k-7
Dere
7, Have you been convicted of any traffic offenses in the last five years?
mg..gl„g�)�im Vit+
Where
When
influence of alcohol or drugs in the last five
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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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 • • AND
D- • • • • •• •• -a
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
deldt"ftbadg 03/2014
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
Ya -e tea' g 123!� . I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that if I false;y 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. (Needs to be signed in front
of a Notary Public)
Date f�
Signature of Applicant
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'„r,,,,,............., k Ll se t ' On this 1 CD t t day of
4*4**4****!*************4**f*4*!**************4***44****!********44*44!**!***************44******k*************!*****4k*********************4*4!
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).
Sign at ” of Pal' ief or designee
V- &/L
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'/a" (width) and 51/2"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
deM=ddvc*d29app2014.dac 03/2014
°°Till 1k 7. 2014 2: 11 PM Div of Criminal Investigation No. 4354 P.
VIII !1 F I' J. L V I T 1 L. J J. n 1 C I L, V I b I n V I t J v 1 t u a u v t) NV e T J I J P.
IIII
III
ffl+�aal� STATE OF IOWA
iG fj1.f, CriminalHistory
r
equestForm
DC1 Amount Number: a "S-
(ftaePllceble)
To; Iowa Division
oCriminal
raon From., Ofofri we Cb ..,.................
Fort Pto ml` tootCity
Clorks Offloo
215 1E.7 street 41016, "4�aShi� gtoo„groat
ONMalnes,Iowa 50319
(515)-12S.6066 ..00wa ritlr, ,1A 52240
/���'` - Phh°aa,n �7t9.3.'"vb••50^t1
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515) 725-6080 Imax
1 am rloalaneatgung anr;l%wn Crirras"tfml Hhbnrgr "Record (Ji oV =
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x'1`'1BAR!Nne.....uusaeo8atlm..:...'......._.....................................................Tt�8�i4D sfi.(tt®rwaV}vo�nelverO t M..V.......... t .... �� (aamrafi 1 eradel (aronaaatadoup) oeiml Securbf Number reeanunza&A)
Z-7
................. ...�,............._......................................................................e............._..._.....................................
�................... ........... .. _........_......
wia6pet°,bdof'avtaa lmtta wuhnlut e sl'o ned waiver ttaar n tUnosubject a1 tho roam vt, n oomplato erha Nat htxtor,P record may not
ha Irotosiam blo,'0ar Coda oflown, Cloapror 69)".r, For ,5.01t?.YO. ertm&nnel bio aary raaorat tnforrcaaa91oo9 as atlawye6 bylmwv, otsva'ys
Waiver Maetes& r
tunvemltplal'lJon MCI). Any
o ficIdfaa condu t an lowrn ra iidaui Vn dwyreonfrn chokwiiffi ere nD ylsion afQfinffi4
mlacA by mne%BU nertay be aeKa: 4m 0.9 SHOWM by law,
As of ..a search of the provided narne and date of birth revealed:
NO Iowa Q'rifnirIa9 l48ttrx'y 1t.eeord found with. Dan;)
1raa 4'.niununea4 11i tat 1t ¢:a card ataeo➢nedy b1l p
qr 77 (08/210)
Received I ime Apr. 2014 12:34PM No, 6587
ODCt life only)
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SMARTEA1, 1 CUSTWVIEF DRIVE
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0111 e aro? @3W4TOY Y
1101 Bux 9204 Don f/dlltl"m A,',
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Certiifrued AlbttrwCt of IID1rlrtiitng IRecolyd
Inquiry Date.
4/3/2014
DL/ID ON
428W189 (IA)
Nissen
Fowler, Eric Dean
Class.
D
Address:
122 1/2 N DEVOE ST
Audit ON
6310503
Issue Date.
09/18/2012
City/State,
LONE TREE, IA 527557742 Expiration
08/23/2017
Date.
Endorsesentsn
2
Mailing Address.
PO BOX 33
Restrictionan
Corrective Lenses, Left
and Right Outside Mirrors
Date of Blithe 8/23/1973
sterling City/State. LONE TREE, IA 527550033 SeNn M
Crtotlan IDa@:a; Oonv irvon gets ACD
II1/02/'201? '111115120 12 II`Mlsca.11 umeous _
11.11/1212012 ., r r/,A 5/20:112
_... �. fS92 Speed (11,0 imp h A under M 35 55 mph
Niasw Fowler„ (Eric (Dean DL/'U.'rd. 428XX x189
11D Status.
None
I1XII. Ststivasu
VAL
CDL States.
None
CDII. Cert Statum
None
CDL Med Status: None
Restriction None
Supplesents
County
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Ottice of Driver Services, Iowa Department of Transportation, do here
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 offic
currently In the custody of said office, and that I have been authorized by the Director of the Iowa Department of Transportal
certify.
EWA ; a
®
Office of Driver Services
Iowa Department of Transportation
Niame. Fowler, Eric Dean DL/ID; 428 5189