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HomeMy WebLinkAbout15-159�1111YJlp� CITY OF IOWA CITY 410 Last Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. 15 —I 5j (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAS 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 IIPL` Id Last 1. Name (REQUIRED) ��/� �H ii tis 2. Address (REQUIRED) W luh Cin �t a C 3. Contact Information (REQUIRED) Email: _�� L✓ w a Gtv} Imo` , (V"' ell Phone: 3 I Gi (All written com munication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) o J A D! 2 0Z 2- b. b. Taxicab Business Name (REQUIRED)_ 1 dVCo5 5. Prior experience in transportation of passengers: V-0-4Dw, X0,01 lcgL(p (A -A b ��eh 1"`C`f 0" tYI Iv Cs/ I ( � ,q K � C',+ U LU, �-Sv ,+✓l ye -a, k ✓I l J.- �L(� � 1.fo l �� 1 "/'� � ud Ill 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?D Type of offense Where When ., What happened to the charge? (Circle one) -« t Convicted Dismissed Deferred Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? ^scYlsc-At c her 1,4V i 751V� r lWl Vfsen" ca Cww Wr1 tlnapp44 " i -cle on. pl Ig I'luy Z-+-� (Uw. sic at happehed to the c�iarge'3{Circle one) `'1 CC�nvicted 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? y [� 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) to f) 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 uporo request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Dep tme t of Transportation a valid Chauffeur's license number n i 2 98 3 � +i, issued on 0 ��20 expiring on 05 /57 ) 6,12, 1 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 ApplicantJDate STATE OF IOWA ) COUNTY OF JOHNSON ) S4cribed ani sworn to before me by r OC Z_-2 (N� on this r day of Cemi,i,;;: ,V P1urr)ber221819INotary Public in and for the State of Iowa 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). �s 11i Signature of F5olKce Chief or designee g.JMI 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. Sifta0e of City Clerk or designee `_ Office Use Only Approved application DCI report State certified driving record Website update /Date N CAO aer, AXIDRivenDGenaaLe2DI4@m--riaw.Doc 0212015 1UA6)► D0T " t; 1WAII10Wc'3t�otgoV ."RTER I<! Fi_F I CUSTO7:':=� rip, dam.„- :. Office of Driver Services PO Box 9204 Des Moines. 1.4 50306-9204 Phone- 51',-244-'124 1800-632-!121 i Fax: 515-235-1837 wwwiowadot. gow Certified Abstract of Driving Record Inquiry Date: 7/17/2015 DL/ID #: 012AA3346 (IA) Customer #: 3632089 Name: Wezeman, Peter Jenkins Class: D ID Status: None Address: 1016 DIANA ST Audit #: 8784482 DL Status: VAL Issue Date: 01/22/2015 CDL Status: None City/State: IOWA CITY, IA 522404627 Expiration Date: 05/18/2022 CDL Cert Status: None Endorsements: 2L CDL Med Status: None Mailing Address: 1016 DIANA ST Restrictions: Corrective Lenses Restriction None Date of Birth: 5/18/1951 Supplement: Mailing City/State: IOWA CITY, IA 522404627 Sex: M History Information Convictions .cation Cate Conviction Date ACC= Explanation County JUR 12/16/2009 03/03/2010 M75 Passing School Bus Johnson IA 02/04/2013 02/26/2013 B64 No Insurance Card Johnson IA 03/19/2013 04/19/2013 N82 Improper Backing Johnson IA 07/24/2014 08/20/2014 B64 No Insurance Card Johnson IA 07/24/2014 08/20/2014 Defective Lights Johnson IA 08/21/2014 09/18/2014 B64 No Insurance Card Floyd IA Accidents - Accident involvement indicated does NOT mean the individual was. at fault or given a citation. ,%, cident Date Case Number JUR 03/19/2013 730956 IA Name: Wezeman, Peter Jenkins Dll 012AA3346 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 sea! of the Department to be set upon this document, at Ankeny, Iowa this date: :••"-"••-r/ 4 7/17/2015 IOWA D. 0. T. r fORIP '{ Office of Driver Services Iowa Department of Transportation State of Iowa Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name ,4pdhdo (mandatory) First Name Primer Nombte (mandatory) Middle NameSegundo Nomb,e (recommended) �e,��k P -e -w i e���� S D�at/e( of Birth Feeka Nacim/,ie�nto (mandatory) Gender Geiwro (mandatory) Social Security/Number recontmended) I � l A, f 8 (� { 5N / [ Male ❑Female t 1 � - �N� ' 7" � Waiver S7 natnr Firma (lf thhee ie/clues[/is-on yoou-rself, please sign, lfthe request is on someonc else, write N/A ) CO DO I e Y Results As of - , a name and date of birth check revealed: b —. Ur > c 4ni No record found w © Record attached DCI # Tl o E3 DCI initials _� D Receipt Number of requests x $15.00 per last name = Total amount $ �� Method of payment: cash money order check # MasterCard or Visa (Last 4 digits) Cardholder's name � l DCl initials 1 V Credit Card # Exp. Date DCI -83 (09/ 09/ 10; Revised 10/ 1 / 10; form reviewed 08/ It/ 14)