HomeMy WebLinkAbout15-070IDENTIFICATION NO. l Z7 —U 0
a 1 (Office Use Only)
let
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 Last Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
..First delle . L st
1. Name (REQUIRED) M PSS� T]C t o"OL V
2. Address (REQUIRED) a
3. Contact Information (REQUIRED)
4a. Chauffeur's License expiration date (REQUIRED) - !Z
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
2(
Cell Phone: X�-UoTf
-mug
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plea//d Guilty Other
7. Have you been arrested/ charged with any traffic offenses in the last five--,-, J r
Type of offense
Where
When
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? J
Type of offense Where When
9. Have, you ever applied to be an Iowa City taxi driver using a different name? If yes, please provtde4he ngTe(s) .
9
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
APIP CATil FOR TAXICAB VEHICLE DRIVER
Page 2
Ilce ty that I hays issued to me by the Iowa Department o Transportation a valid Chauffeur's license number
%L� issued on 22 expiring on � I understand that if I
falsely answer any questions in this application, that this applica ion 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 Titlel of the City Code. (Needs to be signed in front of a Notary Public)
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by T c � e s P 7 nur on this -2f, day of
(tM�;,)� _tniC
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 fre iyt-Pb ice Chief'or designee
V
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.
Signtune of City Clerk or designee Dat
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Clak/rAXIDRIVBADGEAPPL92014.mendad DOC 02/20155
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Clak/rAXIDRIVBADGEAPPL92014.mendad DOC 02/20155
x Mar.16, 2015 11.04AM Div of Criminal Investigation
Mar. 13. 2015 12ARM City Clerk - City of Iowa City
AVIVIA
'STATE /) i /1VJA
( I1 I 1 111 m Rf 'I I e f;ii a P/ Request I o I n
Tot YoWa IDIVI11oa of CriminallnveStigation
Support ®ptvatlous Bureau, V'Floor
215 R. It, street
TDea Mohres, Iowa 50319
(515) 725-6066
(515) 725-6000 itax
I am reauentiutr an Iowa Criminal MistotvReco d Check On:
No. 2508 P. 1/1
No. S/Ui r. Y
pGIRocountNurnbet: i
df
(Iappl(cable)
From. Crty of Iowa City
Clfy Clerl('s Office
410 E. Washington Sfreet
Iowa Clty, FA 52240
p110aU 319-356-5041
Fox: 319-356-5497
LostNatne nlnndamry)
Fir9t10IaM0 nl(ndalot
Middle. Name(rewamiende
In�MaVtn
JaV�P-s
Date ofBirth mandpatory)
Gender (mandalo
Social Security Kutnber tccoinmonded)
r) J—��
Waiver 1ii(forwilonr without it dgtted waiver from the aubjutof the request, a complete crlminal history record may not
be raleasable) per Code of fowa, Chapfer6912,)FoVcowtPIet crlmfpal hfsfory record informaE[on, as allowed by 1aty, always
obtolnawaiverst nafurefromthesubectoftherequest,
Wrdver Refeate: lherehy give pe mission Por tho e6are regvestlA(1 otYleld to conduct nn Iowe eriminol history retard Check With tha Dlviclon Of Comlual
invesUfAllon(DC4. Any crinunal history data co iogmo 00 is dby0t DClrnsy6oreleasedmalfonedbyla,P. P
-
Waiver +Si nature:
(DCI use only)
As of. 3-1(' -1!5 a search of the provided name and date ofbhfhfeVealed:
�A No laws Crirnhial History Record found with DC1
0 Iowa Criminal llistoxyRecad attached, DCf #
belhuials_i,
ReceiveJ Tiime7Mar.13.''�2015 12.40PM No. 2383
C4010WADOT . v
1aMTER l'3 TLT`F i GUSTO,"I F I)RNFA Vi f,Ei iNN its , C
O1fire of Driver SplviCpM
PO Boz 9204 ! Des Moines, [A 5030.3 0204
Phone: 515 244-91241800 5311-112 i i Fa z_ 515-23=3-1337
wvrW_10w.itfat9JV
Certified Abstract of Driving Record
Inquiry Date:
3/13/2015
DL/ID #:
249AD7128 (IA)
Name:
Behrmann, lames Patrick
Class:
D
Address:
320 2ND ST RM 218
Audit #:
7873890
Restriction
None
Issue Date:
03/12/2014
City/State:
CORALVILLE, IA 522412677
Expiration Date:
08/06/2018
Endorsements:
3
Mailing Address:
320 2ND ST RM 218
Restrictions:
Corrective Lenses
Date of Birth:
8/6/1981
Mailing City/State:
CORALVILLE, IA 522412677
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: 8ehrmurm, lames Patrick DL/ID; 249AD7128
Customer V:
1845805
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
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
sald 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 :', 3/13/2015
IOWA
O.T:k.,'
.s
Office of Driver Services
a8 Iowa Department of Transportation
Name: Eehrmann, lames Patrick DL/ID: 249AD7128