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HomeMy WebLinkAbout14-168► r 1 ir"III � *-%As._ CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 Q 19 5040 I319J 35 997 FAX First 1. Name MA(g uthorization Number (Office Use Only) QJy k�x QN FOR TAXUMOTORIZED PED Q'AB VEHICLE DRIVER (iroh'se-De}Zartm ust be made between 8 a.m. to 3 p.m., Monday — Friday.) Last . I '. 2. Mailing Address 3. Telephone: Home ' �3 j 4 Other: 4. Prior experience in transportation of passengers: -C-7y 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Nt 0 Tvpe of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense Where 7. Have you been convicted of any traffic offenses in the last five years? \i�4%4— When Where When i-\/ i-\/ f�©i\tASoln �/k4/f�UIZ 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 1 Type of offense Where When 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) derMp 1drivbadg 03/2014 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number MA(*;�I r i 0 . I understand that if I falsely answer any questions in this application, that this application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will 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 a license is granted, to comply at all times with provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) 7 Signature of Applicant Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by tilsrd cpt t! L. ,Q On this /e) -�( day of �Ot' ` � a A. -a, rA . wENDY S. MATE Qa a otary Public' and for the State n*ieaien Dtu % Commission Expires I I 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). Signatu rr Polic rf or designee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. Signatu of City Clerk or design e Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width) and 5 MY' (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update derWiexidrivbadgea,2014.doc 0312014 Rag.13. 2014 4�08PM Dlv of Crlmina? 1nvestlgat�on ND. 6979 ? 1/1 �u j. Il• CUI'1 J�LJI I'l Itr V I O I t, VI l VI 1Vra VI l)' Nu. JVLJ P• L ■ 1(t ��il-rvY41)TATIE OF ' ^ f �) Criminal ! i . Hisfory 1 \ Reque3t IWO, 1 Form DCJ Account Number: U n e a—F (if applicable) To: lova Divlsfon of CrimiuAl Investigation From; City of Iowa City Support Operations Durcnu, 1"Floor City Clerk's Office 115 & 7'� Street 410 R. w0shington Street Des Motiles, Iowa 50319 (SIS) 725.6066 Iowa City, 1A 52240 (515)725-6080 Fax Plioue! 319 M-9041 Far: 319356.5497 I am req),teAiiig an Iokva Criminal Histoi Record Check on: Lasf Nalne (uioidetory) Firot Name (mandatory) Middle Name (rewmmEnded) �- f k � D t M/ A�D[_Mj\ c�,&�Eo M�� Date ofBirth (mandnigq• C,re)ydel' (b)endetotyJ Social Security Mimber (Tnom oiidm) Male ❑k'enrale Walverbifw'121aClofi; W[thout a signed walver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692,2. For corilete criminal history record fnformatfon, as altewed by lawn always obtain a walyer signature froln the subject of the re oest. w!liVEP REjBlfSB; ] hereby glre pennlstlon Sord 0 above requ silo , ofl tial to conduct a lowo cdo,inol history record eBeck+Yilh rieDlYsien eCCriminal Cnvesligellou (DCO, Mycrlrroinel history dela cwueming mo th 9 maGllen by IheDCI msy ba relessed a, a11o1Yed D11y law. WalverSignafumel WGr Yowa Criminal History Record Check Results (17Clvsconly) As of r< a search of the provided name and date of birth revealed! No Iowa C'b inal History Record found with DC1 d Iowa Cxlminal History Record attached DC1 # DCI iniCials,��1 Received Tilnd'Aug, I'. 02014 3:24 PM No. 6750 Page 1 of 2 .� DoT SMAeg p pyla ryA ��>--1 ,1, - tjvu v,:I�vvaidet.go� SMA 861E It r.. k:'r'11 �f ra 8 21..-1Otklf: f kYfNI Mi Offir.8 of Driver Services PC) Box. 9204 i De., Mkines, IA ;0302-5204 Phone. 515-243'7124 i QO .;,2 1121 €[. c i 1'.235 I:iw7 wVN' 161'!:1%