HomeMy WebLinkAbout15-195CITY OF IOWA CITY
410 East Washington Street
Iowa criy.lowa 52240-1826
(3 19) 356-5040
F3 19) 356-5497 FAX
1 Name (REQUIRED)
2 Address (REQUIRED) 9
IDENTIFICATION NO. %.�`i — I q
(Office Use Only)
APPLICATION FOR TAXICAB / 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
3. Contact Information (REQUIRED) Email:
4a. Chauffeur's License expiration date (REQUIR
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passenge
Middle/. 0`�L
. on
communicatio s ntviaemail)
y
Last
Cell Phone: Je f
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /L) D
Type of offense Where When *ever c rCpe�c
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?
Q
Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
/V U
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
A,)d
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE TIFIF�
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIF7EulW t
You must apply for an individual Department of Criminal Investigation Report (form availa�b orf requerft.-
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) r �, 1=c ''
02/2015
W
rs
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
M cg tY I have issued to me by the Iowa D�p rtm t of Transportatio v d au is license number
1: issued on 0 2� xv expiring on �Z �Jlunderstand that if I
falsely answer any questions in this application, that this ip lica on maybe denied. I Agre at in making this application, I
consent to allow agents or employees of the City of Iowa City, owa, 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 provis 6 j of Tit e 5, Chapter 2, of the i Code. (Needs to be sig ed 'n front of a Notary Public)
Signature of Applicant t� 1 Date Z QHS
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by A d rt c, S on this 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'A license Z6 2 o k V
Signalure of Police Chief or desi ee WDate
AFTERAPPROVAL 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.
/l llC2i�t zv K ��eIJ
Signa re of City Clerk or designee
Date
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a
DCI report
State certified driving record
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Certified Abstract of Driving Record
Inquiry Date:
8/28/2015
DL/ID #:
181AD9000 (IA)
Customer #:
4685633
Name:
Willis, Andrea Lolita
Class:
B
ID Status:
None
Address:
2219 11TH ST
Audit #:
7293771
DL Status:
VAL
02/06/2015
06/04/2015
Issue Date:
08/29/2013
CDL Status:
VAL
City/State:
CORALVILLE, IA
Expiration
06/29/2018
CDL Cert
Excepted Interstate
522411368
Date:
✓4'i
Status:
h��; d./
Endorsements:
PS
CDL Med
None
�'
8/28/2015
Status:
Mailing Address:
2219 11TH ST
Restrictions:
NONE
Restriction
None
Date of Birth:
8/29/1980
Supplement:
Mailing City/State: CORALVILLE, IA
Sex:
F
522411368
History Information
Convictions
Citation Date
Conviction Date
.ACD
Explanation
County
JUR
05/25/2012
07/23/2012
592
Speed
Johnson
IA
11/24/2014
01/04/2015
S93
Speed
Johnson
IA
02/06/2015
06/04/2015
M14
Fail to Obey Traffic Sign/Signal
Johnson
IA
Name: Willis, Andrea Lolita DL/ID: 181AD9000
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
8/28/2015
'v: IOWA
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x1111,
Office of Driver Services
Bel ��o�`
Iowa Department of Transportation 3;
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Name: Willis, Andrea Lolita DL/ID: 181AD9000
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8/28/2015
Aug. 31. 2015 2 : 3 0 P M Div o? Criminal n v e s t a t i o n No.4522 P. 1
From:cI',y of 10we, Ulty Glwrk OfflCe 319 3666497 09/25/2015 11:56 -"-3 P.002/002
>ES rAYT1, OF 10 WA
Criminal Iiisfaf,)f Record Ctle(:!c
R,eq(te�qf Forlrr
'('r,: Iowa Dhdslon ui (Mminal hwmfji aliuu
4III) pOlt Operg[ Ions A,I au,1i1Islow
2151: 7"' Strte(
t)ca Maines, (01Ya 50319
(515) 725.6066
(515)725.6000 Fax
to
Name
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On:
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(if zpplicahlc)
Vr(Im: _Cify of luta 4i •-------------..__._,..---
[!ly Clcl-h'x Qf6ce
41U r, Washin Ion Street
luwa Clty, IA 522w11
Phone: _319-356-5041__
Fax: 319 -356 -5497 --
M /me pecu,nnrenar
Let id �C
U// D V ❑114aEcFemale
.[refwrHrtrrolC Without a signed waiver from the subject of the request, a complete criminal history record may mol
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history rocurd 'information, as allowed by law, 2lw83's
obtain a waiversi nature from the subject of the renuest.
l'Ir6iVer RelCQTe. 1 hofebygiee penniaelall for at abort « q=iing official ro duct an lows ariroinel hislop• record cheek nim the UiYisien o1 Criminal
IgvEstigarion (PCI). My efiminel 6isrnry dela rant ri-g conme r is mainiaincdbyN+e I may bt r cased as allowed by law. \
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Signture:-- — �— _
A8 of
"searcll of the provided name and dale of birch revealed:
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No Jul" Criminal Hislory Record found wish 1701
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lows C'rinlinal Hislol'y Record atl"cheJ,17(']!J Md 1 3 Wp E5"'
DO initials-_-/
1)(1.77 (08/2511 n)
Received Time Aug, 2B, 2015 11:48AM No, 6105
(Uta use anh)
Aug,2015 2 � 3 1 � V Div of Criminal tovesIigat!on
No. 4122
P.
2
IOWA CRIMINAL HISTORY DCI 01013136
COURT DISPOSITION PENDING PAGE 1 OF 1
CONVICTION STATUS UNKNOWN DATE PRINTED-
2015/06/31
DCI:01013136
NAME: WILLIS,ANDREA LOLITA
DOB SEX. RAC HGT WGT EYE HAIR SKN POB
198DO629 F B 502 160 8R0 ELK LER IL
ADDITIONAL IDENTIPIERS PHOTO AVAILABLE: Y
TAT CHEST
TAT R ARM
TAT R THGH
CCH RECORD tet*
01 ARRESTED 20141003
AGENCY: IA0520200 IOWA CITY PD
CHARGE NO- 01 IA STATUTE IA715A.8(3)-A
IDENTITY THEFT
TRK#: 1A00JXL01
02 ARRESTED 20150810
AGENCY: IA0570000 LINN CO SO
CHARGE NO- O1 IA STATUTE IA715A.5
TAMPERING WITH RECORDS - 1987
TRK#: 5ADOR3N01
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON-LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION
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