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Home My WebLink About15-126CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319)356-5040 (319)356-5497 FAX IDENTIFICATION NO. 15- -7 5 --7 (Office Use Only) NO c drtue 1 S Tpr �1 1 CqJ a APPLICATION FOR TAXICAB /MOTORIZED PEDIC/ �[FHI DR1qI2 (Police Department review must be made between 8 a.m. t ern.,- onday--Friday) =E C) N .+� 1- Name (REQUIRED) 7rv��T 2. Address (REQUIRED) �%C� / i �H f%l/�/✓✓C �!✓F� C /�l/S ✓ 1 !L �C 3 Contact Information (REQUIRED) Email: �r�1G�hCT;7G-i=�rC�llklu=CellPhone:�l�-4(p�'�(J1�� (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) L) b. Taxicab Business Name (REQUIRED) M A 2C -2 -S :::EA KI 5. Prior experience in transportation of passengers: \/K 3 6. Have you ever been arrested 1 charged with any misdemeanors and/or felonies in this State or elsewhere? A Type of offense Where When What happened to the charge? (Circle one) Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When Ste: /ir eJ ( /+ J What happened to the charge? (Circle one) Costed 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? 0 �/ ) 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 nalne(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) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 N 0 u+ I hereby certify that I have issue"o me by the Iowa Departme t of Transportation Val[ f�CEeur"icense tuber 7n /I n issued on -_7 expiring on / it uWersta hat if I falsely answer any' q estions in this application, that this a lic ion may be denied. I gr—w racing this apation, I consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examinand all res and documents relating to this application, and I further agree that, if authorization to be a taxicab driver r,4ntez o c at all times with all of the provisions of Title 5 hapter 2, of the City Code. (Needs to be�signed i front Q � lot ftc Pu is Signature of Applicant � Date L STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by C`3P_t if .pF1�,�_�gr0 ! 1� on this 11 �„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 015 61% i 'Jl I �a-� Signsture 6f Police Chief or designee c)(n If 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. Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update DaJ aamended ooc 03/2015 Q010WA00"T SMARTER 19MPLER I CUSTOMEE DRI[Vft d WWW' iowadi'tgov Office of Driver Services FO Box 9204 1 Des Moines, lA 50306-9204 Phone: 515-244-9124 1800-532-1121 C i=ar 515-239-1837 www_lowadoi History Information Convictions Citation Dave _.... Conviction Date _..... Certified Abstract of Driving Record Explanation County Inquiry Date: 6/4/2015 DL/ID #: 700A30627 (IA) Customer #: 6101512 Name: Bickford, George Frederick Class: D ID Status: None IV Address: 401 9TH AVE Audit #: 7011629 DL Status: VAL Issue Date: 06/06/2013 CDL Status: None City/State: WELLMAN, IA 523569338 Expiration Date: 01/15/2018 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: PO BOX 296 Restrictions: NONE Restriction None Date of Birth: 1/15/1967 Supplement: Mailing City/State: WELLMAN, IA 523560296 Sex: M History Information Convictions Citation Dave _.... Conviction Date _..... ;rCD Explanation County JUR 11/23/2013... .09/05/2014 -. S92 _S .. _..... Speed ;S _. Johnson ;q Name: Bickford, George Frederick IV DL/ID: 700AI0627 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: •:�/6 6/4/2015 IOWA ;A 1.0. T.` = '04evWMA ........... BNfB Office of Driver Services ntiv Iowa Department of Transportation Name: Bickford, George Frederick IV DL/ID: 700AI0627 .FeC�IUn, 5. lUl`J� I)6Fill rF01v 0T_GYlminal_1nveSt19aI109 OSIDA12016 10:_I90.0 1113Y. I/L1002 STATE ATE OF IOWA Criminal History Rectlyd Check Request Form To: fovea Division of Criminal Investigation Support Operaiiuns Bureau, t" Fluor 215 G. 7'" Stmot Des iMoines, Iowa 50319 (515) 725.6066 (515) 7256080 Fax DCl Acenunt Number: 1+0 O :� fifaYpRtnble) From: Chy of luwil City _. City Clerh's office 410 F. Washfnfton Street lova City, 1A 52240 Piton e: 319-356-5041 Fax: 319356-5447 I am re uesung an Iowa w snuaaa sllaaw Lost Name (mandatory) 1lG4,V1V 1"..1 V.., First Name (mandatory) Middle Name pecosmnended) Date of Birth (mandatary) Gender (mandatory) Social Security Number (rae0nmpended S � �� ale ❑female 2,1Ll_g1_7�7 Waiver Inforniation. Without 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 comnletC cridninal history record information, as allowed by law, always oblain o waiver signature frmn the subject of (he req -nest. lvnever Release: I hereby give permission for the above requesting offtciel to conduct an Iowa willioal historylecnrd check with dsc Division of Criminal Invutigelion(DC). Any criminal hislory daU concerning tile that is maintained by the ay be released as allowed by law. Wainer Sig)iature: _ _ Iowa Criminal History Record Check ResultS_ s "' (DCLpse only) I T1 �J ' As Df �P a search of the provided Warne and date of birch reve4— t No Iowa (:,•imine] 1•1istory Record fouCDM with DCI M _ a D >w r N G' ® Iowa C'idninal History Record attached, DCI DCI initials LUCI-77 (08125/10) Received Time Jun. 4. 2015 10:34AM No -6635