HomeMy WebLinkAbout15-103IDENTIFICATION NO.
(Office Use Only)
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APPLICATION FOR TAXICAB I 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 East 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
F'.s/t f/ // MiddleY Last
1. Name(REQUIRED) �yr,'5`77•✓I�r% C� r/P5 6 r9A
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2. Address (REQUIRED) j 9,2- IJ 14 Sfra t
3. Contact Information (REQUIRED) Email: Cr �,, r 1e s r c s h . c cy +- Cell Phone -?1'2
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) or; d0
b. Taxicab Business Name (REQUIRED) _ /-I ek r C, C
5 Prior experience in transportation of passengers: /3 e, k.„
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? -E
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? ,Nd
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? /Vc
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please plWide thaaaame(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA RTIMED rI
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICEC414F I3FVIEVk.n,�
i
You must apply for an individual Department of Criminal Investigation Report (form av u%pn relMt).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) Cn
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to e by the Ia De art ent of Transportatio a valid Chauffeur's license number
C20 S I %h/ i 3<,mssueowd on a3 2nW expiring on Y sv 1vac, I understand that if I
falsely answer any questions in this application, that this a pli ation 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant s Date /S _2v15 -
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by CnC' zj-oa��-. C_ J�SS4 auQn this day of
Public in and fbr the State of Iowa
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 City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license I L,� 2
L__
Signature o ice Chief 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.
Sign-atmof City Clerk or designee
Date
0
Office Use Only
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Approved application
DCI report
State certified driving record
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Website update
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ClerkffN IDRIVBADGEAPPL92014am.nded.DOC 03/2015
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Div of Criminal Inv e s t i g a t i o i DCI 101v .7229 P. 1/1
NATE OF IOWA
Criminal History Record Check g� _
Request Form
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To: Iowa DM91011 of "Mioal Iavestl8alon
Support Dpenitons Burma, PI F)oor
215 E 7° Street
Dat Metas, lova 50319
(SM 73.56066
(515) 715.6080 Fair
DCI Account Number: 4383 -FL
MpQtkahre)
From:arG.STrxi
11 54ve-S Or -
0410 A 5 aj'l 0
Phone: ,� 319 338- 614
Fait.. 3 (1 351-899
Last Name fir)
Prot Name
Middle Name a .mwd4
J
Gander��/,
Social 8aclarl Number ,eaom metOA
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I aie OFetnaie
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Wallor Inforn a don. Without a signed waiver from the sobjeet orthe nqueat, a complete comical hirtory record may not
be rclessable, per Code of Iowa, Chapter 6W.2, For f&MWgje erimb ld blefory record Information, ar slowed by low, always
obtain a waher Agahure fro0 the 1 an olike reguat.
Waiver Re/Case; i hereby tiro permialon faraw shout requeula6 oalalal is cooduw a town wlmhol bemo,y word check welb ere Dlvhim or climhul
Imepeaedea (DC7) �r cdminJ hlmry dM wr,wmina maJat H ar Weed ty 4o DCI nay b telesud u Jlowad q Isr,
WalverSignatare, r
As of 4J 16 (1 "� , a saarch of the provided neuro and date of birth rovealed:
No Iowa Criminal History Record Found with DU
Iowa Criminai History Record attached, DCI
DCI initials.
Received Time May, 4. 2015 10:01AM k 6980
(DCI we arty)
..
UVVA DST .
Office of Driver Services
PO Boy 9204 , Des Moines, i4 50306-9204
Phone: 515-244-9124 1800 532 11211 Pax_ 555-2;1+-1837
www.iowadoa.go'r
Inquiry Date:
Name:
Address:
City/State:
Mailing Address
Certified Abstract of Driving Record
5/12/2015
Bergen, Christopher
Charles
1920 H ST
IOWA CITY, IA
522402029
1920 H ST
Mailing City/State: IOWA CITY, IA
522402029
DL/ID #: OOSWW9836 (IA)
Class: D
Audit #: 8006344
Issue Date: 04/23/2014
Expiration 04/30/2020
Date:
Endorsements: 3L
Restrictions: NONE
Date of Birth: 4/30/1965
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Bergan, Christopher Charles DL/ID: 005WW9836
Customer #: 4138394
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert None
Status:
CDL Med None
Status:
Restriction None
Supplement:
Pursuant to Iowa Code §321.30, 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:
•""•••'r/r, "
5/12/2015
IOWA`' - f
r'"••••"__
Office of Driver Services
�sally =—'
Iowa Department of Transportation
Name: Bergan, Christopher Charles DL/ID: 005WW9836