HomeMy WebLinkAbout15-164CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
1, Name (REQUIRED)
IDENTIFICATION NO./ �—% l n q
(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
2, Address (REQUIRED) e aU.L
3. Contact Information (REQUIRED) Email.
comm
4a. Chauffeur's License expiration date (REQUIRE
b, Taxicab Business Name (REQUIRED) TE'i f
5. Prior experience in transpo ation of passengers:
_i-. ot C� L,�h
ln7'-' I Cell Phone 31 1 I — �2
viayemail) CCIn
C;
I _
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Where
When
What happened to the charge? (Circle one) N/A
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
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 ive years?
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the ^Wme(s)
1"Vr o eta w"
--------------------
y C—
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE((ORTIF
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CRxrrruREwW I�
You must apply for an Individual Department of Criminal Investigation Report (form availjp)lpolLrequ
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)`u N
ko
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I h�ye issued to me by the Iowa Dep rtme of T II�portation v d Chauffeur's license number
7�Y YG 103 issued on��ifg on o I understand that if I
falsely answer any questions in this application, that this a licati may be deniedagre 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 Ci)y Code, (Needs to be signed in front of a Notary Public)
Signature of Applicant /Ld�rrl�{. �•� Date811432015
STATE OF IOWA )
COUNTY OF JOHNSON )
bscribed and sworn to before me by_11/\rl7AAec �_ on this day of
WENDY S. MAYER
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 !�> 1 I Gi / 2�
6 /(-�< %�5
Signatur 7 k,6Chief or designee
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
Date
Office Use Only
N
Approved application
r 7- ,
C)
�..
.
DCI report
State certified driving recordu
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Website update
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Clerk/ IBRIVBAGGEAPPL92014.mendedDOC
03/2015
CAIowa Department of Transportation
cvice of Ofrm seiwes i ICA! (tee) WO 532 1121
P4) Dox 9204, GIs Moines, 44 50306 9204 51s-244 9424
O, PAX 515 239 1931
Certified Abstract of Driving Record
Inquiry Date:
8/10/2015
DL/ID #:
769YY6103(IA)
Customer #:
915880
Name:
Heath, Thomas
Class:
D
ID Status:
None
Edward
Address:
2801 HIGHWAY 6 E
Audit #:
6044993
DL Status:
VAL
LOT 394
Issue Date:
06/13/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
05/19/2017
CDL Cert Status:
None
522402658
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2801 HIGHWAY 6 E
Restrictions:
NONE
Restriction
None
LOT 394
Supplement:
Date of Birth:
5/19/1959
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522402658
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
]UR
07/07/2013
07/18/2013
S92
Speed
Linn
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
3UR
09/19/2011
648797
IA
Name: Heath, Thomas Edward DL/ID: 769YY6103
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:
8/10/2015
IOWA
D. 0, T ��.
�qW_
1, "P,
Office of Driver Services
Iowa Department of Transporation
Name: Heath, Thomas Edward DL/ID: 769YY6103
Aug.11, 2015 11:32AM Div er Criminal Investlgatien No.2725 P. 4%11
Fro MJCliy of Iowa City Clerk Office ale 36e6497 O6/10!2016 12:03 4196 P.0021002
13TA TE , (IF IOWA
r,
} Cl-intinaf History Record, Check
'1'u: Ipwa I)ivisloll of Criminal Ltvestlgafion
Support Opernlions Idure&u, 3"Plnnr
115 R. 71r Street
I)es MOM, Iowa 50319
(515) 725-6066
(515) 725-6000 Pax
1 a,m re uesUu fn Iowa Criminal
Last %Manse f(n,Iar,dalory)
I-7 eQTY�
Date of Bil-tb (,nal,da,ory)
s/WE7
_F�,,OrnQ5
1)(:1 Account Number: --
(if applifahk)
City Clerh's Office
410 E, Was))I tan 5lieet----�— — -.
Iowa City, 1A 52140 __�------x-----
Pbone: 319-356-5041
Fax, 319-356.5499 —�---
Male ElFemale
Eel w (zzrxj
_2S81
rr'(uver injorl9raffo1r,, Without a signed waiver from the subject of Phe request, a complete el Iminal history record ma) --
be releasable, per Code of Iowa, Chapter 692.2. For co_ mOcte criminal history record information, as allowed by jaw, ahvaps
obtain s waiver sivnaurre 1r.. rt— ,.kla ._fn - -__..__r
1'I ih-8r Release:1 hereby give tienllissiun ror die above fequesIing official to condual an folyy tdmuoal historyfecord Lbuk Willi the Division of Criminal
lavcsligalion(DCI), Any aimioalhistory dataconcerningme Ihallsmainlainad by Ibe DCI mayt+c released allomed law.
Iowa Criminal History Record Cheek Results — -- —�
(Oct list only)
As of_�//� � a Search of (he provided name and dale of With revealed:
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r Nn h„va Criminal j-Iis(ur)r Record round ;,ii(1, rca
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