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HomeMy WebLinkAbout15-120IDENTIFICATION NO. /!j — % aIQ i (Office Use Only) 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. loiva 52240-1826 Failure to complete the "required" information will result in denial of the application (3 151) 356-5040 (319) 356-5497 FAX First Middle Last 1, Name (REQUIRED) i.. uli aAN7 F CCot�a2 2. Address (REQUIRED) _J20f, f VAfj4 Y . aouyq C'jTy TA C2.24C> 3. Contact Information (REQUIRED) Email _'CCcj�,n 1236 (S>Vol�oD. Ccs r� Cell Phone: 3t9—L} I-�G4Z (All written communica ton sent via email) 4a. Chauffeur's License expiration date (REQUIRED) I Z �2y 1201 S b, Taxicab Business Name (REQUIRED)_C o� 5. Prior experience in transportation of passengers: S urQW& dnivil Cola V INA Suu TgX1 Cad+ 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? C-1 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? V -C S . Type of offense Where When -re, 4pTti4�FlC SIRn Stsin�l �Ou15c CLT+J jjjjg 12010 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? 00 Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please proviq the naWe(s) ?J © -AM C— _ DEPARTMENT OF CRIMINAL INVESTIGATION (DCB) REPORT AND STATE C22R 14FIE15 �. DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C EMW You must apply for an individual Department of Criminal Investigation Report (form availa oaque to (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) q w 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number ss yt,l (, & 13 `I issued on T expiring on 1212(1 11 C . 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Eji4 Date b 12) 15 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by , r; A. C LO, j eScoh . r on this ��{� day of -_I'u V -C 2�I.r 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). fu^^( S, 10/5 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. 7/ k7j�,.-r1: K . !lam Signature of City Clerk or designee Approved application DCI report State certified driving record Website update Date Office Use Only gn a r r M rn 3 C.0 Q ClarkTPA IDRNB.AocaaPPLszoiaamand�d. ooc 0212015 Frc,uit, 4. LU 7,,,71�)4RIVIcjerlUlV 0T LrIrrinal IOVestlgatioll N0. 9901 F. 2/2 06/03/2015 la; -v !3111 .. �.,.,�/DD;q STATF OF IOWA CYimingl History Rei ord Check (&I Request Form 'rnr Iowa Diwisims of Criminal fnvestigatlon SuPPort Operations Bureau, I" door 215 F. 7'h Street Des Moines, Iowa 50319 (515)726-6066 (515)7256080 wax m au Iowa Cruninal Iiisforry Record Check on: DCI Accomil Number; `l by (if applianble) From; Cit oflownCis ---� City Cleric's Office i 410 Jr, Washington street lutea City, YA 52240 Phone: 319-356.$041 FRX: 319.356.5497 - — — —' e 0na,dalory) First 1K2111e (mandamTJ Middle Name (recomn rth imandamry) Gender mandaiogq Social Security Nun, 1 q al Ld11YI81C ®Female _ psi- X334 vralver lraforrlrrrtiOn: Will'OUta signed waiver from the subject of the request, a complete criminal history record may no( be releasable, per Corte of Iowa, Chapter 692.2. Por cam lete criminal history record information, as allowed by law, always obtain a wt, iyer slant, lure from the tit, hierr Ir rho .<....0�3 Waifver Reieras'e: I Gereby give pern,lssion for the n60ve aqucsin@official to eonduel an lusro criminal hislary record check with she Division of Criminal Im'essigasion (DCI). Any cri minau,issory dale concernieg me spas is rnainlained by me DCI may 6e released as allowed by lam. Waiver M.-itatur-e: W t 1 Iowa-sriminai Ristoi Recon d Check Resuits��� fuel n:e (1nly) _ a search of the provided name and dale of birth revealed: I No Iowa Criu1L111 Hislor}' Record found with l7C1 n'i Iowa C6miva1 History Record attached, T)CI µ l; d DU hlilials—.,� Received Tlme ,tun. 3 2015 2;22PN No, 9766 #C410WADOT v0pAvio aidat.gov SMARTH 1 SWPFR i (USTOMEF DRIVEk1 Office of Driver Services PO Box 5204 Des Moines,. A 50306-9204 Phone: 595-244-8124 1 800-532-1121 ( Pax: 515-235-1837 ww _lxraadot.gov Inquiry Date: 6/4/2015 Name: Chay Escobar, Luis Alfonso Address: 1206 DIANA ST City/State: IOWA CITY, IA 522404629 Mailing Address: 1206 DIANA ST Mailing City/State: IOWA CITY, IA 522404629 Convictions Certified Abstract of Driving Record Dil #; 555XX6834 (IA) Customer #: 406903 Class: A ID Status: None Audit #: 9027580 DL Status: VAL Issue Date: 04/22/2015 CDL Status: VAL Expiration Date: 12/24/2015 COL Cert Status: Non -Excepted Intrastate Endorsements: P CDL Med Status: None Restrictions: Except Class A Bus Restriction None Date of Birth: 12/24/1963 Supplement: Sex: M History Information Citation Date Conviction Date ACD Explanation County IUR 11/18/2010 12/09/2010 M14 Fail to Obey Traffic Sign/Signal "Johnson 'IA Name: Chay Escobar, Luis Alfonso Dil 555XX6834 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 ............ r,4ti 6/4/2015 D.0.T :. i r f ®RIVES Office of Driver Services ^`ate Iowa Department of Transportation Name: Cray Escobar, Luis Alfonso Dil 555XX6834