HomeMy WebLinkAbout15-063I r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) 1I S
IDENTIFICATION NO. /5-71DLe-A
(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
2. Address (REQUIRED) H CU Q&+Yht-�C t -11-- N -. lower
3. Contact Information (REQUIRED) Email: lcx ct, r j$(c} ry)O j `CQYIy
(All written communicatiod sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
Phone:SL',,� G-11 a 2S70
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Tvpe of offense
Where
What happened to the charge? (Circle one)
C ' Ismissed Deferred Suspended Plead Guilty — ' ther
Have you been arres d / charged with any traffic offenses in the last five years?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred SuspendePlead Guilt Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? -
Type of offense Where
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 D part ant of Transportation a valid Chauffeur's license number
��572- BFSZ issued on Z� expiring on � I I ZL0I� . 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 5, Cha ter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature ofApplican _ Date �J
*w*xw**w*xwww,e*.kw#*axww*.u**x*xxxxx*w*#xx*w*w**xxm+xwwwwwwwwxwwwwwwxxwxwxxxwxwwwxxxxwxxxw*xxxxxxxxxwxxxxxxxxxxxx#xxxxxxxxxxxxxxxxxxxx*xxx*x-xxxxxx
STATE OF IOWA )
COUNTY OF JOHNSON )
nuPscribed� and sworn to before me by I 4 1ALJ S c)v� on this / -J'y day of
I have review is application, DCI report, and the State certified driving record of this applicant and have deter-
mined th there i no ation which would indicate that the issuance would be detrimental to the safety, health
or welf a of resi of th City of Iowa City (Title 5, Chapter 2, City Code).
Signature cr Pobee or designee 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.
Signature of City Clerk or designee
Office Use Only
Approved application
111
/ Date'
DCI report
State certified driving record -' -
Website update - —
cled MIDRNsno3EAPPL92oia@men-C d.DOC 02/2015
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:
First Name P,vmer So,nb,, (mandatory)
Address: j\(kj
2
City/State/Zip: ( — Z
Phone #: t y G�
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name-4pEflido (mandatn[y)
First Name P,vmer So,nb,, (mandatory)
Middle N/ vrE (nxom;mendcd)
ja }me�srepi?,to.vm„
Date of Birth Fe ria v , : r,,tin (manaam )
Gender c aero imenn ttwi
Social Security Number (nxormninacsll
El Male male
Waiver Sign at ure F,rmu (If the request is (m your.sdf. please sigr. ICthe raiuest is on su_mwne else- write N) A)
Results DQ USE of ILv
As of a name and date of birth check revealed:
[] No record found
❑ Record attached DCI #
DCI initials
Receipt
Number of requests 1 x $15.00 per last name = Total amount $ 5. b 0
Method of payment: /I cash
Cardholder's name
DCI initials
Credit Card #
money order check # MasterCard or Visa
(List 4 ft]Ll)
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
Exp. Date
CIowa Department of Transportation
AO Office of Omfef Scram (Tdl Free) 800-532-4121
PO BSC 9204, Des I,tWM, IA 503069201 515-244-9124
1=A)C 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
3/17/2015
DL/ID #:
845ZZ3882 (IA)
Customer #:
4146095
Name:
Hudson, Lindsey
Class:
D
ID Status:
None
10/05/2010
Nichole
F06
Violation of
Motorcycle or
Moped
Requirements
Johnson
IA
Address:
1100 ARTHUR ST
Audit #:
7925503
OL Status:
VAL
02/09/2015
APT N1
592
S eed
Johnson
IA
Issue Date:
03/27/2014
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
05/01/2017
CDL Cert Status:
None
522406618
Endorsements:
3
COL Med Status:
None
Mailing Address:
1100 ARTHUR ST
Restrictions:
NONE
Restriction
None
APT NI
Supplement:
Date of Birth:
5/1/1989
Mailing
IOWA CITY, IA
Sex:
F
City/State:
522406618
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
05/01/2010
05/20/2010
S93
Speed
Johnson
IA
10/05/2010
11/23/2010
F06
Violation of
Motorcycle or
Moped
Requirements
Johnson
IA
10/29/2014
12/03/2014
593
Speed
Johnson
IA
02/09/2015
03/09/2015
592
S eed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
3UR
05/01/2010
570190
IA
10/29/2014
824027
IA
Name: Hudson, Lindsey Nichole DL/ID: 845ZZ3882
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:
+` 3/17/2015
I�
44
Office of Driver Services
Iowa Department of Transporation
Name: Hudson, Lindsey Nichole DL/ID: 845ZZ3882