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HomeMy WebLinkAbout15-144l 1 . Pr.�r r® 'III SEE CITY OF IOWA CITY 410 East Washington Street 62240-1826 19)356-504D (319) - 7 FAX IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB I 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 First Middle Last 1. Name (REQUIRED) _. 2. Address (REQUIRED) —2- 3 3 Contact Information (REQUIRED) Email: U Cell Phone: (All written communication sent via email) 4a. Chauffeurs License expiration date (REQUIRED) ) f b. Taxicab Business Name (REQUIRED) < 5. Prior experience in transportation of passengers: r r, 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? 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? Type of offense Where E When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ Type of offense Where When 0 r _ 9. Have you ver applied to be an Iowa City taxi driver using a different name? If yes, please pro4the' me(p r DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE eERTIFIED ti ' DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE &FIEF Rli c,3 You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 I APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number issued on expiring on 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 - Date " i STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by 7) .t <lAt S L Edi ere on this )j, day of 'Jud ��t5 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 a r/l /15 Signature ofof Police or designee �7ate jl 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. SignMure of City Clerk or designee ate Office Use Only r, EE Approved application' ce DCI report r— State certified driving record w Website update { �w Clerk/TAXIDRi a DGE PPL92014amendedACC 0312015 P z � 5 � / � § _}\\ . $ \ G) G ~ \}qo�(k k / ) 0 \ \\\\\ �\ }\\�_ / � \ % \ - 2 C/) / \ \ / / \ ƒ \ En P\ \�\« k \ 0 0 ® } � { 2 I { / g e / \ 010) : ( CL / / § § ° c }\�\ � 3 f \ \ ƒf\2 (cc§ { f J / / § 2 s a o 2 ; \ \ {/f( o «CO \\\ 0 \ j Fw { \ / ƒ _\\\ \ \ % 2, § ;\( C ° E!!z/rR{ #3`a0 0 Sc 00x000 WC k ) §|.0 \ < .3- { R - | 0 E ■ r . . k � k { \} / \ E||�f0CL CL cr § \3 , , • `! !\ /o CL i\> k\(ƒI/ 7 ° �;§@;� - §& f§��- iuI,132015 1,39'114 Div of Crimina,i 1nveO i W im NO 0790 P. 5 Fru „i:�.-r .y u, ,owe any Cl crrc Office aYs 3E 66a 67 Obnoi 2Uti6 72:nY N76S F.a02i opt STATE OF IOWA Ci History Record i 1 rI Request Form To: Iowa Division of Criminal hrvesliga(ian )Jupport (lperalioos 8nren V, I" Monr 215 r, 7" Street WE P'lolnes, Inwo 30319 (515)725.6066 (515) 725.6090 lax TQiin > an Iowa e (n,andalpra(fT�e F bate of Tilrth (mandatary, 2L- (-2,'w rirst Name boaada 1DC1 Account N imbor 400 - (if epplicabic) From: CO oi,101va Cft City Clerh's OFGcc 410 r, Wasliin Icon &treci lows CiIS', 1A 52240 .,•_-, ----- -_ I' h on a: 319-356-5041 Fax: 319-356.5497 Lta ale ©Female. U0oDS X8 2.6 o /9-?/ fl'aivep rnf0MM(iol1; Without a signed waiver from the subject of the request, a eomplete criminal history record may not he releasable, per Code of Iowa, Chapter 692.2. For co. molete criminal history record Information, As allowed by law, al)vays I11r!liVCY IiCreBSC; l hueby Rive permission foe Ale above 2gacariog aA9oial ie eonduul 8n Inua criminal history rwOrd Check wish the DiVi3ion of Liminal Inves(1941oil (DCI). Any criminal history data eomeml[> is roainta e the nC1 mar b= released as allowed by law. Waiver Signature: (DC1 use omy) As nFy—�Ira search of theprovided naDle and date of birth revealed; _ / I No Iowa Criminal ]lislDry Record found witlr I>Cl L„ rI --I n C1:'- 111 17 town Qiminal History Record atlached, DC:I ca _ llCl initials_--_--� air t.•; y D01-77 (08/25110) Received. Time Jul. 10 2015 12:00IJ No. 9784