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HomeMy WebLinkAbout15-104IDENTIFICATION NO. JS -10g 1 l 1 (Office Use Only) APPLICATION FOR TAXICAB 1 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 S2240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX [st i. Name (REQUIRED) FIK>o(�(� Middle Lastj C,e 2 t je ,r 2. Address (REQUIRED) lb .S3 C r'C,S .RAC r Ct" tt 6 i �_�� Ca 522 Y& 3. Contact Information (REQUIRED) Email: bott'f r t (Cy (e Y� ".e C oar Cell Phone: 81Cr - 32 1 — 7 6cl f (All written communicatiort sent via email) 4a. Chauffeur's License expiration date (REQUIRED) 7 i21 f t Q b. Taxicab Business Name (REQUIRED) C floc. t" A T,%. A c r"w 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? CS Type of offense Where What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Have you been arrested / charged with any traffic offenses in the last five years? ,r e' Type of offense What happened to the charge? (Circle one) Convicted Dismissed Where When 7 ev Deferred Suspended Plead Guilty Other Ff of 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 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). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby cert that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 1"�`IG {i 1. 6, 76 issued on 511/3 expiring on7/2-/II 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 of Applicant �iy Date STATE OF IOWA ) COUNTY OF JOHNSON 1 S�b�cribed and swornto before me by he 0�4 �. (Lt 1°2�-I on this ICii /N day of 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 _ 2 L l aJ Signature of Poli � G� eEef r 6esignee 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. t) Sighsi of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update Clerk/iAXIDRIVBADGEAPPL92014amended.DOC Date a cn 03/2015 May. 13. 2015 11:55AM Div of Criminal Investigation No, 7086 P. 1/3 Fr.-.,.�..,. STAFF OF IOWA. Criminal History Record Check I f bequest Form To: Iowa Divlslon of Criminal Investigation Support Operations Bureau, 1" Flood - 215 E. 7" Street Des iloiues, Iowa 50319 (515)725-6066 (515) 725-6090 Fax 1 am rbnuestiurr an fnwa. Criminal Aictnly Rennrei C11enic nn - CA i DO Account Number: _l jCJt� (if aypliwblc) From: City of rows clay City Clark's Office 410 C, Washington Street Iowa City, JA 52240 Phone: 319-356-5041 _ Fast —319-356.5497 Last Name (111andatory) First Nance (Ineada(my) Middle Name peeomm<nded) 1C-" Po i6 of _ Date of Birth (manda{ory) Gender (/n,andaloW _ Social SecurityNumber (reeomrkiodto) 7 2 ( /1r iP IIffIVlale ©Female 3 5-(c — (v 2– —?,j O _7 Waiver Inforonalbaal: Wit not a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For combtete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request, Waiver Release; I hereby give pernnission for the above equesting official to em,ducl an Iowa crimi,W history record check wi,h dm Division of Criminal Invesligalion(DCI). Any criminal hislory data eonurni me dial is maintain by,be DC a^be rcicascd as allnwcd by law. Waiver Slgnatrtre: Iowa Criminal History Record Check Results (DCI me only) As of a search of the provided name aDd date of birth revealed J r; (A rr.:.� _, _ I f e ; ; :; a r,.l No Iowa Criminal History Record fouled with i)CI��- U 77 Iovara Criminal H'istoly Record attached, I)CI #_ 7> N UI Dcl illitials� DCI -77 (03/25/10) Received Time May, 12. 2014 9:48AM No.6978 10WA00T SfA!"RiTE315IV, PLliR,iCUSTON'I `41 Office of Driver Services PO Box 9204 ; Des Moines, iA 50306-9204 Phone: 515-244-91241 8UG: 32-1121 I fax 555-2:19-91+37 vevrr_1o' wadrr:.gov Certified Abstract of Driving Record Inquiry Date: 5/19/2015 D -/ID #: 690AJ9763 (IA) Name: Riley, Bobby Joe Class: D Address: 320 2ND ST APT 104 Audit #: 6909763 CDL Med Status: None Issue Date: 05/01/2013 City/State: CORALVILLE, IA 522412658 Expiration Date: 07/21/2018 Endorsements: 3 Mailing Address: 320 2ND ST APT 104 Restrictions: NONE Date of Birth: 7/21/1967 Mailing City/State: CORALVILLE, IA 522412658 Sex: M History Information Convictions Customer #: 5937812 ID Status: None IOWA DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction Nz= Supplement to S -aC 1 5 .1 �1 x Q Z!, f� 7 Citation Date Conviction Date ACD E—planatlon County JUR 01/27/2014 €05/07/2014 M14 Fail to Obey Traffic Sign/Signal Johnson IA Name: Riley, Bobby Joe DL/ID: 690A39763 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: ;r•""••:v��:p 5/19/2015 IOWA D. 0. T..":- , , Office of Driver Services Iowa Department of Transportation Name: Riley,. Bobby Jae DL/ID: 690AJ9763