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Home My WebLink About15-127r �t arlll�� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52 240-1 82 6 (319) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. / s—%d �7 (Office Use Only) APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m, to 3 p.m., Monday - Friday) Failure to complete the "required" information will result in denial of the application 1. Name (REQUIRED) Om 4 5 2. Address (REQUIRED) 310 5 7 ✓C 3 Contact Information (REQUIRED) Email: 005 /Y Qn (All written comm 4a. Chauffeur's License expiration date (REQUIREP) b, Taxicab Business Name (REQUIRED) Cf 01,4 �C4 5. Prior experience in transportation of passengers: I1 d l Middletai mrl Last j v4A {y l 1A 2 n Cell Phone: tia email) daaa- 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 7 VVI for IiaNNcucu LU LlleG (VlrQe one) onvicte Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? II L 0 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? dr r�t (D Type of offense Where When 9. Have you ever ap lied ed to be an Iowa City taxi driver using a different name? If yes, please provide the �name(s) UC, DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATfai -77 DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE 49 RE-VIi 4 " You must apply for an individual Department of Criminal Investigation Report (form avwlioUT W �recM). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTAR G 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby ertfJify��t,h� t I hay issued to me by the Iowa Dep rtment of Transportation va Chauffeur's license number �/ /'�rl h y issued on 0/ expiring on vN 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 employee of the City of Iowa City, Iowa, in their discretion, to examine any and all records and documents relating to this applicatio nap her agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of T r 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date D ' /)` jo/5-- STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by -Tu�m s on this 12- day of ,5",k -1,01S 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 O� �3r I20ZZ q3 oc�l5 is Signature of Polirb 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. Signatur •of City Clerk or designee Dat Cl.d 7r IDRIVBADGEAPPL92014amended.Doc 03/2015 nJ 0 Office Use Only C_ -may Approved application =1¢"s 7n DCI report -D State certified driving record as Website update �- »x W o PQ Cl.d 7r IDRIVBADGEAPPL92014amended.Doc 03/2015 -o n. 201 3:06PM Ulv or Criminal nv,stigation N 0081 P, 2/2 FYL.r•.�. .y .+• ,uw.e �.y Cl wrk �.n �n arc, a000 uar O8/04/2OIS l5:'c v115 STATE (IF IOWA j Cidil� inat klitory Record C1�eek 0I ��;;� .', Request Frsrl To: Iowa Division of Criminal Ltvvetlgauu❑ Support Operations liurcau, 1" Floor 215 F.• 71" atreet Deg Moines, Iowa 50319 (515) 725-6066 (515)725-6090 Rat I am reouesliue an Iowa Cr•inl'mul Nicln•„ nnr vd f`I, n. 4 DO Account Nomlimr 9r- _ fir al,plicab e) Front: City Clerlt's Office 41.0 E. Waghin ton Street Iowa City, IA 52240 Phone: 319-356-5041 Fax: 319-7564497 Last Name (Inaneatc y) I'irat Name (mandatory) T, ltliddlc hrame (reacn AAN TI�MA lenatd> Date of Birth (mand.tc ) Gender (n,nnelmr)) Social Security/ Number (recommandm) OI 13I I U ale ❑Female _ —A rri Waiveil IflfOrm0fi011: Without a signed traiver From the subject of the request, a complete criminal history record may not be releasable, per Code of larva, Chapter 692.2. Cor conlolete criminal history record information, as allowed by law, always oblain a waiver signature from the sub'ect of the re nest'. 1'Ilaiver Release: i itueby gha permission far the abov re ,stir o official to woduct.n low. criminal history record check n9th du Division of Criminal Invcnigaion(DCI) Any criminal hislmy dal. cOncarniog , MR Iby lilt ,ay be released as allowcd by law. Kowa Criminal History Record Check Results As of s search of the provided name end date of lir h revealed: r "' Ln _ —A rri No Iowa Criminal Sdisloi'y Record fowld with DCI 1 L' o ❑ Iowa Cj'iulinal 1-listory Record attached, DO aX )> r �' v- DCl initials, -,- 1)C1,77 (08/25/10) Received T l m e Jvn, 4. 2015 1:14PM No. 9919 Iowa Department of Transportation ovice of Umer `�ervlces f coil f Tee) hili} 532 1121 F 0 Box 9?D4. Ues F ernes. lA 503D6 `52e04 515244 9124 %100 FAX 515 239 183( Certified Abstract of Driving Record Inquiry Date: 5/30/2015 DL/ID #: 614MM6249 (IA) Customer #: 4955997 Name: Hashman, Thomas Class: A ID Status: None Francis Address: 831 STATE STREET Audit #: 7985855 DL Status: VAL PL History Information CLEAR DRIVING RECORD Name: Hashman, Thomas Francis DL/ID: 614MM6249 CDL Status: VAL CDL Cert Status: Non -Excepted Intrastate Issue Date: 04/16/2014 City/State: STORY CITY, IA Expiration Date: 01/31/2022 502481523 Endorsements: LP Mailing Address: 831 STATE STREET Restrictions: Corrective Lenses, PL Except Class A Bus Date of Birth: 1/31/1978 Mailing STORY CITY, IA Sex: M City/State: 502481523 History Information CLEAR DRIVING RECORD Name: Hashman, Thomas Francis DL/ID: 614MM6249 CDL Status: VAL CDL Cert Status: Non -Excepted 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 IOWA D. 0. T. Name: Hashman, Thomas Francis DL/ID: 614MM6249 5/30/2015 4 Ar � f 4 S Office of Driver Services Iowa Department of Transporation Intrastate CDL Med Status: None Restriction None Supplement: 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 IOWA D. 0. T. Name: Hashman, Thomas Francis DL/ID: 614MM6249 5/30/2015 4 Ar � f 4 S Office of Driver Services Iowa Department of Transporation