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Home My WebLink About15-148� t t �► rlll AI CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) - 2. Address (REQUIRED) IDENTIFICATION NO. t S '-1i y O lUtC' L? A Z (Office Use Only) Q APPLICATION FOR TAXICAB I MOTORIZED PEDICA"HI C-0 DITI� (Police Department review must be made between 8 a.m. tln. onda6--F C7 "G Failure to complete the "required" information w111 result in i�lntaI orthe a rst Mid le / Las r,3,,: GE /�r2Fi x lr C7 7N �./�. n'/i 3. Contact Information (REQUIRED) Email: -A ��. �rO 1ftkluellPhone: 2✓I�-4(p�� (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) //IS /2 O b. Taxicab Business Name (REQUIRED) M A R CO ; --FA X S S. Prior experience in transportation of passengers: \/K � 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 4, 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 SJR: r>,,,)C - Where C 1.3 , 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? Type of offense Where When J 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 N Z7 I hereby certify that I have issued_jto me by the Iowa Departme t of Transportation �,, ali � ur'�icens dumber 4 r (7/ issued on 6 expiring on frl upererstawe hat if I falsely answer any questions in this application, that this apflicafion may be denied. gre that ia'mrAing*this aprMtion, I consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examinete and all re s and documents relating to this application, and I further agree that, if authorization to be a taxicab drivernte0 co ntat all times with all of the provisions of Title 5 hapter 2, of the City Code. (Needs to he signed i fronta?(�ot r� Pu is Signature of Applicant Date N ;n STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by mop F. 111 on this Ht -3. 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 0do'75 1240k% Signature df Police Chief or designee 0L) If ff�_ 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. � e. 7"2 Sign'atore of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update - X aerwrw IDRIVenocenPPL92014amend=d.00c 0312015 C--41U'VU1A DOT VVVAnriowado civ SMAPTER I �UAPHR I (USTOMIEP DRIVFN ww Office of Driver services Po Box 9204 g [les Mo€nes, IA 50306-9204 Phone: 535-244-9124 1 80[-5'32-1921 1 Fax: s15-239-1837 wwwiciv,'adot gov Inquiry Date: 6/4/2015 Name: Bickford, George Frederick IV Address: 4019TH AVE City/State: WELLMAN, IA 523569338 Mailing Address: PO BOX 296 Mailing City/State: WELLMAN, IA 523560296 Convictions Certified Abstract of Driving Record DL/ID #: 700A30627 (IA) Class: D Audit #: 7011629 Issue Date: 06/06/2013 Expiration Date: 01/15/2018 Endorsements: 3 Restrictions: NONE Date of Birth: 1/15/1967 Sex: M History Information Customer #: 6101512 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: Iowa Department of Transportation Citation Dare Conviction Date ACD Explanation County JUR 11/23/2013 ;09/05/2014 [S92 ;Speed Johnson IA Name: Bickford, George Frederick IV Dli 700A)0627 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•' ---" :�/�� y, 6/4/2015 IOWA �' f f•® r ice of Driver Services __ "nn Iowa Department of Transportation Name: Bickford, George Frederick IV DL/ID: 700A30627 FfeJUll. h, 2Uih, J: U0!VI_1 araU 14 D?oimina l_ Invest iga( ion 06/04/201610:e VD. UU61113 r.—1/Z /002 STATE OF IOWA Criminal History Record Check (91 Request Form To: fovea Divlsian of Criminal Investigation Support Operatiuns Bureau, V Floor 215 C. 7" Street Des Moines, Iowa 50319 (515) 725-6066 (515)725-6000 Fax V .— . — 1-- r`.•i of lliclnv noe•rorA ChPA a Ave oip DCI Account Number: (if sYPhcnbic) Froin Clry of Iowa City _. city clerll's Office 4fo 6. Washington Street lows Cfly, IA 52140 phone: 319-356-5041 Fax: 319-356-5497 Last Nave (mandaeory) First Name (mandatory) Middle Dame (recommended) Dale of Birth (mandatory) Gender (mandatory) Social Seeurityj Number (reeomn;ended S ale ❑Female %� Lf Waiver Mforrotaliofrr Without a slgned waiver from the subject of the request, a complete criminal hismrp record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver si nature frmn the subject of the re nest. WaiV81' ReleaSe: I hereby give permission for the above rcgncsling officiel to conduct an Iowa ciiinwoi wssory recotei check ulds d¢ Division of Criminal hwcasilation (DC), Any viminel historydale concerning am shat is mainsamcd by lilt "y be /cleated es allowed by Iarv. 1FnitrerSigrtnfure:_ Iowa Criminal History Record Check Results ; (DCI ps<only) As of ✓ , a search of the provided Warne and date of birth /eve rth V ' , n ry Dt X i n No Iowa Criminal History Record found with DO nz _ a D zw G_ ® Iowa C final 14istory Record attached, DCI DC1 initials DCI -77 (08125110) Received Time Jun, 4, 2015 10:34bM No -0635