HomeMy WebLinkAbout15-0911 r i
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO.
(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
First Middle Last
1. 1(REQUIRED) %h-- fes S,nM U(i- rAn'-sa (\),I
2. Address (REQUIRED) MI S , -74,1 AVV- r61J4 C 4Q
3. Contact Information (REQUIRED) Email: r ^;�;� s �S�s �w y�4 / r� Cell Phone: 3(9' 54/ 4y� I
(All written ccn nicatid sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) MAi460S
5. Prior experience in transportation of passengers: 7a `� �✓,Cs rf- 71-V D0 iV 1461
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? AUOO
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years? AJJ
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 1V0
Type of offense Where When
Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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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 Repoli (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
APPLICATION FOR TAXICAB VLI IICLL i3RWER
Page 2
I hereby certify that I have issued to me by the Iowa Departfnen of Transportation a valid Chauffeur's license number
- f3 /:—:- issued on -A�7.2 expiring on /r2/i 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
fimes with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
c-
Signature of Applicant —" Date 64x3 Its
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed I and sworn to before me by e S S P Sc 5 on this 3 rry day of
Public in
S.
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 ity (Title 5, Chapter 2, City Code).
Expiration dof Chis ense��� 0
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 designeeDate
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Office Use Only
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Approved application
DCI report
State certified driving record
Website update
ClekfrAXIDRIVBADGE PPL92014amended, DOC
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03/2015
Mar, 21. 2015 2:27PM Div of Crinlnal Itvast19ation No. 3627 P. 8/9
03/26/2015 13:47 FAX i DCI IOWA 00,077p
STATE OF IOWA
Criminal History Record Check
' Request Form
Del Account Number. "1303"�G
(if *Oinblo)
Tor Iowa Dlvhloo of Crtminel inveetipdoo From1 VAaV 45 7-41
Support operatlana Bumu, I^ Floor
216L7wStreet 5}Gw a pr•
Des Molner, Iowa 90319 l�
(615) 7556066 wa, k 544 O
(515) 7256080 Far (% a
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Last Name m.ad.
First Name jtaaqo) I Middle Name r
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Date of Birth m.,e.o )
Gender Soclal Security Number(noosontrAtto
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12maie ❑Female Sas - I`3 - Slz 9
Walverin.rornwlbR; Without a Aped waiver !Yom the trebled of the requeft, a complete erlmlast hlnery record may not
be releanble, per Code or Iowa, Chapter 692.2, For jyypjo ertmlaal hldery record laformstloe, as allowed by law, ahvays
abtahl a waiver xl@sturg from the subject of the EMUL
WQIVer )Nhlase: I bmty alw rwmimion in ao.bow rogumho ollkW to tonom an low cAn&-1 hhory twid cluck wish de D ririoo o(CAmlral
fftn%dWlen(DCT), Any aimL..I himydm meo.r 4 rM dalh mWwiod M no he mk"Watra.wedbyl.w
Wa1wr ftnature:
Iowa rim' History Record Check Results (DO Mq,,y)
As of r a search of the provided name and date of birth revealed;
No Iowa Criminal History Record found with DC1
❑ Iowa Criminal History Rccord attached, DCI N
I,
DCI initiala�
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Office of Driver Services
PO Pox 1204 ; Des f✓ornes. !A 50 n--5.20<4
Phou, 515-244-91241.80'0-'32-1221 j Far 55.5-239-1£37
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Certified Abstract of Driving Record
Inquiry Date:
4/23/2015
DL/ID #:
434ZZ0578 (IA)
Name:
Parsons, James Samuel
Class:
D
Address:
801 S 7TH AVE
Audit #:
6719710
CDL Med
None
Issue Date:
02/23/2013
City/State:
IOWA CITY, IA
Expiration
02/12/2018
522406205
Date:
Endorsements:
3
Mailing Address: 801 5 7TH AVE
Mailing City/State: IOWA CITY, IA
522406205
Restrictions: Corrective Lenses
Date of Birth: 2/12/1981
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Parsons, James Samuel Dlil 434ZZ0578
Customer #:
4732685
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert
None
Status:
CDL Med
None
Status:
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 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:
a.......... !7di,t�
4/23/2015
IOWA W o,
fAmin c�
Office of Driver Services
"`1.,M1T-„
Iowa Department of Transportation
Name: Parsons, lames Samuel Dill 434ZZ0578