HomeMy WebLinkAbout15-081IDENTIFICATION NO. 2r5 —O`k i
(Office Use Only)
-4
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Street
I ow Cit , Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
rJ (319) 356-504
(3191 3 -5497 FAX
First Middle Last
1. Name (REQUIRED)
2. Address (REQUIRED)
3. Contact Information (REQUIRED)
4a. Chauffeur's License expiration date (REQUIRED)
a
5.
d --X bb% Z� Cell Phone: 3(Q -950'073,4j
nication sent via e&il)In I, „n r b*n
�'3 -1�0/17—
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Tvpeof offense
I1A3) W/1%
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested I charged with any traffic offenses in the last five years?
Tvpe of offense
What happened to the charge? (Circle one)
Where
When
7
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
Mo. M
Y
7-1
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).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
'Page 2
I hereby certify th t I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
issued on `t -13-10Q, xpiring on ct 13--2bt'$ . I understand that if I
falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Titl Chapter 2, of )he City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant �� 10�--1f i Date 4
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and swom to before me by �_�, �� >�-PPS on this o%+it, day of
.A 4—
Public
_
Public in anWfor the State
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code). d
Expiratio ate o a eur's license I L J! T
or
A
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CF* FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
A44� ?' . ems✓
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
clerkrrMlDRIVBADGEAPPL92014anwded.DOC 0312015
Apr. 3, 2015- 1:11PM Div of Crim nal Investigation
11 Y 1 L. a V,) , I V 111 u 1 1, V, e l Y 1 r V I I V R e b I L
No. 4198 P 1/1
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N`161��FIYL'p�
STATE OF MIA .•�/y'^�'••,��.
CriminzlIsio �':fs J -I O� ( f1 f'.:
I< IDWa `I , r..
Forni
(if appirm—ble)
To: town Division of Criminal Investigation
Support Operatlolls Bureau, V Floor
215 E. 71 Street
Des Mohaea, Iowa $0319
(515)725-6066
(515)7IS-6000 Fax
Cavninel
From; City of Iowa City
City Cleric's Office
410 E. Washington Strut
Iowa City, IA 52240
Phone: 319-356-5041
Fats 319-356-5497
YYrti'Verl' rltlrldion: Without a signed waiver fl•om thasubJect of the regucst, a complete criminal histo agOrd icy not tr
be releasabib, per Code of rnwa, Chapter692.2, F'ot cofiDlete criminal history record Information, as allowe w, spiry'
-
WalperRelearme lherebygive pennissionfnrtheaboverequeallegofficial toepndectanlowscriminal hitlory amid ohulnvflh1heDivhi nrdll;rinr9
rnvesdgadoll(LCO. MYcdmbtalhis(mydata oonrsnahl moll mala(elnedb Cl may he ieasedarellowedbylew.
WadperSigltntur� CD
IIOwfl Criminal History Record CheckResults
roclwaee,yi
As of 3 a search of she provided Warne and date of birth 1'evoaic&
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No Iowa Crulwlal History Record found with DCI
Iowa Criminal History Record attached, DCI #
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DCIinitials %WL
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Received TI")"^ �"P` 2015 8:16AM k 4009
C410WADOT
v1nr,w. iovvadot,ov
SMARTER 6 SI'Y;PLU i CUSTOMIP DRIAN
Office of Driver Services
PO Box 9204, Des Mornes, !A 503Ga-92204
Phone. 515-244-91241800-832-1127 1. Fax: S15-239-1:337
:WWw-iriW1doi
Certified Abstract of Driving Record
Inquiry Date:
4/2/2015
DL/ID #:
428XX5189 (IA)
Customer A: 4327574
Name:
Fowler, Eric Dean
Class:
D
ID Status: None
Address:
122 1/2 N DEVOE ST
Audit iF:
6310503
DL Status: VAL
11/02/2012
11/15/2012
Issue Date:
09/18/2012
CDL Status: None
City/State:
LONE TREE, IA
Expiration
08/23/2017
CDL Cert None
527557742
Date:
Status:
Endorsements:
2
CDL Med None
Status:
N
Mailing Address:
PO BOX 33
Restrictions:
Corrective Lenses, Left
Restriction NtqjB
and Right Outside
Supplem C"
Mirrors
Date of Birth:
8/23/1973
Mailing City/State: LONE TREE, IA
Sex:
M
1
527550033
4-0s
History
Information
� O
Convictions
CJatien 0:ote
Conviction Date
ACD Explanation
Count;=
JUR
06/21/201208/31/2012-
ff'g •••9b
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Miscellaneous _
]ohnson
1A
11/02/2012
11/15/2012
Miscellaneous
Muscatine
1A
11/02/2012
11/15/2012
S92 Speed (10 mph & under in 35-55 mph zone)
.Muscatine
:IA
Name: Fowler, Eric Dean DL/ID: 428XX5189
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:
?:..... '7`I '4
•
4/2/2015
IOWA.'l
D. 0. T.,e,
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Office of Driver Services
Iowa Department of Transportation