HomeMy WebLinkAbout14-253CITY OF IOWA CITY
410 East Washington Street
Iowa Cit 2240-1826
(31 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Mailing Address (REG
Authorization Number
(Office Use Only)
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APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.)
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First
I ACt
3. Contact Information (REQUIRED) Email:C a { 6Q D5q bQ bn8. Cell Phone:,
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? rUQ
Type of offense
Where
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?
When
Type of offense Where When
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? �1%n
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 u ame(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATP..CF'RTI D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form avallabte'up5tt request).
(OVER FOR REQUIRED SIGNATURE AND NOTARY) = rt
09/2014
I hereby certify that I hav issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
'1d i3� j �( . 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. (Needs to be signed in front
of a Notary Public)
Signature of Applicant � <> 6 — Date - 4Z"` 1
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 _! ` u F� t a ® �, On this j _ 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).
Signature of Poll q hof or designee Date
YOU ARE NO'i"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.
Signatbra of City Clerk or designee
-- 'Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 5'/z"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ClerkrrAXIDRNB GEAPPL92014=ended.DDC 0912014
Iowa eof 14'ansportatiorl
FI) Bay ltcmw FAX', 5 1 Sr239, I WJT
, ON Wines,A003064971 X4449124
Pursuant to Iowa Code §.321.10, I, IKlm 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 wllnersof„ II have caused my si gnahire and the seal of the DellaarU neat to be set upon thils document, at Ankeny, Iowa
this date:
i
� a X114 ,, 11/12/2014 � ¢,
a ,rm ur"I IIIA
m� r�
Office of Driver Services
Iowa Department of Transporation
rtNflttd Abstract
of DillAlllig Record
In0uiry natm
11/12/2014
iii./I® #:
243AD8454 (IA)
Customer &t;;
5402235
Namner
Smith, Linda
Class„
D
ID Status:
None
Mohamed
Address
1076 CHAMBERLAIN Audit
6847075
IDD. Status.
VAL
DR
Issue Date.
04/09/2013
CDR... statum
None
Clity/altatea
IOW1fA CITY„ IA
Expiration Onto.
04/04/2018
CDIIL. uCeivat titentus:
None
522402952
Eridaraenmen z
3
CIDL. Mod Status.
None
Mailing Addmasz
1076 CHAMBERLAIN IRestrictlonsi
Corrective Lenses
Restriction
None
DR
xuppllemomt:
Date of Biirth:
4/4/1980
Neill!
IOWA CITY, IA
New
G
Clty/ Otxu
522402952
Histairy
It1fifo rlllltli't'dtllll'd
Pursuant to Iowa Code §.321.10, I, IKlm 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 wllnersof„ II have caused my si gnahire and the seal of the DellaarU neat to be set upon thils document, at Ankeny, Iowa
this date:
i
� a X114 ,, 11/12/2014 � ¢,
a ,rm ur"I IIIA
m� r�
Office of Driver Services
Iowa Department of Transporation
Namwi Smith, Linda Mohamed DLIXD- 243AD8454
I
Nov, 18. 2014 9:24AM1 Div of Criminal Investigationy
STATE OF IOWA
1' A
Criminal History i' eco d Check
k
'rqr I'a m
on„of Criminal filvestigAtion
Support Opentiong Burson, r,ploor
219 F. 7'6 Street
Des , 50319
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From: R°&apr o fowaa C((.
P ons® 319..356-6041.
No. 4329 P. 1
—, ',1.L
(6fAPPODabfa)
No Iowa Cr1nikal lllataayy Record.faunal vdiffiDC1
Um
Received Time'�Nov.13.1�2014 8:43AM No.3942