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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. `� r
_ C:) a
(Office Use Only)
�f�IJ�w Cab
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Failure to complete the "required" information will result ill denial of the application
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Middle
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Last S r
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3. Contact Information (REQUIRED) Email: tv r Cell Phone:
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 4---4 Z Z 3 —
b. Taxicab Business Name (REQUIRED)
315 - 41 / ?3 4S
5. Prior experience in transportation of passengers: fa \Evr rS CV, ry
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Tyne of offense I 0 - Where When
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What happened to the charge? (Circle one) _
Convicte Dismissed Deferred Suspended Plead Guilty Other _
Have you been arrested / charged with any traffic offenses in the last five years?
V -,S ti2015—
Type of offense Where When �""V
DIV C
What happened to the charge? (Circle one)
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? Q
Type of offense
Sp.QrGi I*
Where
When
2 1--olliQ -fin n�zv &II e S>i s L, .4 1 z (7 1 2 20 ( 3
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)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
_ D 2 p �R I d—" issued on expiring on 1 understand that if I
falsely answer any questions in this application, that this app icati n may be denied. I a ree th t 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant_ 'I�N Q A,1�1 Date 3
r �
1 'T 2015
STATE OF IOWA ) py C tv
COUNTY OF JOHNSON 1
Subscribed and sworn to before me by -0 0 0 i tO Q . on this / izit day of
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that th o information which would indicate that the issuance would be detrimental to the safety, health
or welfare residen s e C of Iowa City (Title 5, Chapter 2, City Code).
designee
2q//r
I /Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR.
Signatu'ro of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
7 415-
Office
5
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State of Iowa
Division of Criminal Investigation
215 E. 7" Street
Des Moines, Iowa 50319
Plione: 51.51725-6066 Tax: 515/725-6080
Iowa Criminal History Record Check
Walk -In Reanest
Your name: '0 A V l p j1CX
Address: 3o f
City%State/Zi : <DuA>R C`.v�� locucti 8¢22 f
Phone #: 3ici— 4-7t—
Requesting
-7
Requesting an Iowa criminal history record check on:
Fill in all shaded areas. ~; R
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Last Name Apeiudn (mandstnry)
FirstNombre(mindatoty)
Prijm
Middle Name9,gurtrla
\Name (e,
,/nJo_rn'bre(recoinmended)
Date of Birth Fecha jvcrclmlurto (mandatory)
Gender Genera (mandatory)
Male ❑ Female
Social .Security Number (r ommcndcd)
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Waiver Signature Firma (If the request ison yourself, please sign. If the request is on smneonc else, write N/A.)
Results I
DO CSF:ONLY
As of j =% a name and date of birth check revealed
No record found
❑ Record attached DCI #
DCI initials �.AA
Receipt
Number of requests �_ x $15.00 per last name = Total amount $ 1 S• 0 O
Method of payment: cash money order check # MasterCard or Visa
(Last 4 digits)
Cardholder's name
DCI initials
Credit Card # Exp. Date
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
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