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HomeMy WebLinkAbout15-065]LI • rlw®��'il d. CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. '`� Llu (Office Use Only) 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 in denial of the application 308 50-1" Middle M 3 3. Contact Information (REQUIRED) Email: fV r� r Cell Phone: 31i''- 4"7 r 7.3 ¢S (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) +'--a )- " Z 3 — Z© ) `3 b. Taxicab Business Name (REQUIRED) JC3 wq Vl 5. Prior experience in transportation of passengers: 6 lune r CV, 11r 1 -15 cc -t-) 1VA 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Yes Type of offense 1 _2 UWhere ac9SS. C0 y Sv� 4lri� 1.4 4 When I - What happened to the charge? (Circle one) Co( nvicted Dismissed Deferred Suspended Plead Gu � Guilty Other }� 7. Have you been arrested / charged with any traffic offenses in the last five years? -0S Type of offense Where When City C!L,:- Ova C!tv, 10 v, 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? -!E? Type of offense Where When S p-prcQ 1 � S q 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 so--) p �9 i � (n issued onfiexpiring on I understand that if I falsely answer any questions in this application, that this app icati r, may be denied. I a ree ThTt 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 Q Date 3 Ix - STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by n� ti� Q. }}c3,� ]1LP j_ on this / 7 tk day of I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that the.a-is^no information which would indicate that the issuance would be detrimental to the safety, health or welfare f esidenejs o-tIeC'pty of Iowa City (Title 5, Chapter 2, City Code). 14Ail 17 2015 ate Cit; Cier1,. 10v12, citv, to -- 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. /� - eatiLl Signat4e of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update 3117 /5- D afe Cleiwr IDRIVBADcenPPL92014zRiende.d.00C 0212015 State of Iowa Division of Criminal Investigation 215 E. 7"' Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk -In Reauest Your name: z A V I p M 6 rl CA Ha W p S 4z Address: City/State/Zip: ofoc�_ —7pc.Jc\. 54221 Phone #: I '% -- 73 Reauestine an Iowa criminal history record check on: Pill in all shaded areas. Last Name Apellfdo (mandatory) First Name Pr inner Nombre (mandatory) Middle Name Sagnndo Nombre (recommended) HC,( t j S Dpv(0 P/� �%L MO -Ob SP Date of Birth Fecho Nteeunzento (mandatory) Mender Genero (mandatory) Social Security Number (recommended) Male ❑ Female �? l �L Waiver Signature Firma (it the regircstis oil yourself; please sign. If the reyuesr is' on someone eine, write N/A.) Results [JCI USE ONLY As of / , .- a name and date of birth check revealed: No record found ❑ Record attached DCI # DCI initials b Receipt Number of requests i x $15.00 per last name = Total amount $ 1 S• 0 O Method of payment: X cash money order check # MasterCard or Visa (Las[ 4 digits) Cardholder's name DCI initials ---------------------- 0------------------------------------------------------------------------ Credit Card # Exp. Date DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14) m y m m m m a 0¢ 0 0 0 0 n z> z z z z N Z R Ip •• in in ] Ln w CcE E Y ] q a u m u {y til Gf N N1 N J J J N 6 D U U C N 4-3 O p O N co O m N N m N N O+ Y W N \ \ N N N w v \ \ Z Z N w K N Om O m o O [n N E u R 1f -. Z• LL L n m E m m m a c w r� wso v l y � vMi a w 0 O N K N vl +D a n¢ z M S M U a Q y Nr m W N q C O1 E a y i C �< <<< 4 n .... N C C C o a o 0 c p C Im/i N Vai V C C o r ] C C C m L L L d° U o 0 o '�' n m u c m ] u Q i C N 4 O ti a N o a o 0 c p V C C o r C '�'