HomeMy WebLinkAbout15-071' I r ccy
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. / 5 —a —7 1
(Office Use Only)
APPLICATION FOR TAXICAB 1 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 in denial of the application
3. Contact Information (REQUIRED) Email: t;Lcr'NY'Gt,, I(D, (yGuu.'I. CO &1 Cell Phone: M-473-30%
(All written communication sent via email)
4a. Chauffeur's License expiration date (R
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: floU
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? %1
Tvpe of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? do
Type of offense Where When
What happened to the charge? (Circle one) V
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? 7C5
Tvpe of offenseWhere When
f1or.:,- l�au Me(` 61 E4,)c.>v O'W d A Z -13 - o 4
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
7�Q cel
75 issued on ?+i$-7015 expiring on Y 17-20I5- . 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 Title hapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date 3 �Z6 %`J
xxxxxxxxxxxxx+++xx++++++r.+++++++++++++++xx:uxx+xx++>xaxwwxx+w++xxxxxxxxxxxxxxxxxxxxx+++++++++++++++++++++++xx+xxxx+xxxx+xx>x,ur:++xxsx:exxxxxxxxxxxx
STATE OF IOWA )
COUNTY OF JOHNSON )
q cribed and sworn to before me by N c i Slyp ler L Tr 1 r jL- on this 4 day of 2-6
1 C3 77
26
My
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 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).
Expiration date of Chauffeur's license Y Z 2—Y12-0 2 -3
Signature f lice Chief or designee
'Z, 61 r
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.
Signature of City Clerk or designee
3AU /is
Date'
+xxxxxxxxx+xxxxxx++xxxxxxxxxxxxxx++xxxxx+x+x+xxxwwwxxxxxxxxxxxxxxxxx++++++x+++x+xxxxxxxxxxxxxxxxxxxxxxx+x++xxxx:xxxixx++xxzxx+xxxxxxxxxxxxxxxxxx+
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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a search oflheProvided name and data of birth revealed:
No IOWA Ohnillal History Record found with DCI
Zobva Criminal MStorq Record aft0ched, DCI
DCTirutials��
:eived Time7N�ar.�"fb'�hn,�
(nciu ee„Iy)
CIa wa Department -of Tr an
Office of Driver Seruim (Toll Free) i&dii-532-1121
P€)130X. 97114, OEs 110111, IIA 59316,11209 515-744-9124
-'# r FAX: 515-Za i837
Certified Abstract of Driving Record
Inquiry Date:
3/22/2015
DL/ID #:
769YY1758(IA)
Customer #:
1272105
Name:
Lottich, Christopher
Class:
D
ID Status:
EXP
JUR
John
Suspended
02/13/2009
03/15/2012
D53
Address:
3701 2ND ST TRLR
Audit #:
8934357
DL Status:
VAL
2
Suspended
03/04/2009
12/21/2009
D38
Issue Date:
03/18/2015
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration Date:
04/24/2023
CDL Cert Status:
None
522412795
Accident
Suspended
Endorsements:
3
CDL Med Status:
None
Mailing Address:
3701 2ND ST TRLR
Restrictions:
NONE
Restriction
None
Iowa Fine
2
Supplement:
Date of Birth:
4/24/1979
Mailing
CORALVILLE, IA
Sex:
M
City/State:
522412795
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
I Case Number
JUR
112/22/2008
480109
IA
Sanctions
Type
Effective
End
ACD
Explanation
Occurrence
JUR
JUR
Suspended
02/13/2009
03/15/2012
D53
Non -Payment of
IA
IA
Iowa Fine
Suspended
03/04/2009
12/21/2009
D38
Fa it to Post
IA
IA
Security for an
Accident
Suspended
06/02/2009
03/15/2012
D53
Non -Payment of
IA
IA
Iowa Fine
Name: Lottich, Christopher John DL/ID: 769YY1758
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:
3/22/2015
a —
fe r
Office of Driver Services
Iowa Department of Transporation
Name: Lottich, Christopher john DL/ID: 769YY1758