HomeMy WebLinkAbout15-194r t
CITY OF IOWA CITY
410 East Washington Strect
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(-3 19) 356-5497 FAX
IDENTIFICATION NO. /S -J9q
(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
rst
Middle
Last
1. Name (REQUIRED) Kotnil' / Np-1 .-[/4ektr--S
2 Address (REQUIRED) ?.? 2 4 -11 %v..,-, C. fz SLz y 0
3. Contact Information (REQUIRED) Email: iteTo Gir14,r. w,>r Cell Phone: (3( / s--* "/oJ-i
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ Va/>v 6%a,
. Prior experience in transportation of passengers: -C4P..5
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Ys
Type of offense Where When
i7l,F51S,al 14C ezx, 2 -
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended lead Guilty 'Other
Have you been arrested / charged with any traffic offenses in the last five years? qe5 o
Type of offense Where )
rn 1
! 2X edd,n.c; /.- sI•h3�+n_,_Lr' rte;-" 8 --?Di2.—
Iv
What happened to the charge? (Circle one)r
Convicted Dismissed Deferred Suspended Plead Guilty ''F'Other`b
y� o
8. Has your driver's license or chauffeur's license been suspended or revoked in thethe a lead
rltyd
Tvpe 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)
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)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
/Fd 41 Cc 4616t Z_ issued on o3 -rH IS expiring on -s3i-lk . 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 stall
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!ic,„r- z- r S
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me byon this
02 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 �l J k� /
Signaturef Fro!' hief or designee
I,/z/2_c:�5
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.
_)Ila -",) K - -�
Signatu're of City Clerk or designee
Date
Cl M l DRN6ADGEAPPr92014amended.Doc 03/2015
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Office Use Only
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Approved application
ris
DCI report
x"
State certified driving record
—
Website update
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Cl M l DRN6ADGEAPPr92014amended.Doc 03/2015
C410WAOGT wwwrJowadotgov
SMARTER I SIMPLER I CUSTOMER DRIVE ��
Office of Driver Services
PO Box 9204 i Des Moines, IA 50306-9204
Phone- 525-244-8124 1800-532-1121 1 Fax: 5155-239-1837
www.iowadot-gov
Inquiry Date: 8/26/2015
Name: James, Robert Anthony
Address: 1225 120TH ST
City/State: WAYLAND, IA 526549542
Mailing Address: 1225 120TH ST
Mailing City/State: WAYLAND, IA 526549542
Convictions
Certified Abstract of Driving Record
DL/ID #:
184CC6142 (IA)
Customer #:
Class:
D
ID status:
Audit 9:
8930946
DL Status:
Issue Date:
03/18/2015
CDL Status:
Expiration Date:
08/31/2016
CDL Cert Status:
Endorsements:
2
CDL Med Status:
Restrictions:
NONE
Restriction
Date of Birth:
8/31/1987
Supplement:
Sex:
M
History Information
4589431
None
VAL
None
Excepted Intrastate
None
None
Citation Date Conviction Date ACD Explanation County JUR
02/05/2012 02/28/2012 S92 Speed '_Washington IA
Name: James, Robert Anthony DL/ID: 184CC6142
Pursuant to Iowa Code §321.10, 1, 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:
;: °'•"'•!`!�"4y
8/26/2015
Iowa' .A
D. 0. T.;d°� f
CA
%f'••• •"e
Office of Driver Services
Iowa Department of Transportation
Name: James, Robert Anthony DL/1D: 184CC6142
FAu€.28; 2015,,10�18AMo�arDly of Criminal Investigation oat„zO�s No. 4348z�P. 2%2002
STATE, OF IOWA
0-ilnillai History Record C;hech
Request Form
't'o: Iowa Division of C.l-inainal ]rrvesligstiuu
Suppm'I Operatinos Bureau, I', Flour
215 G. 7'h Street
Des l7olnoa, )U.va 50319
(515) 725-6066
(515) 725-6060 Fax
am requestjn an Jowa Criminal liisto)y Record Check on _
Laet Name (,nenaalcq) _ First (Name (mandatory)
e -
)
)ate of Birth
;y�ifr'L
Dt:. Auuunlllunlbea': Ltood'F
_.......cif sppiicalilcj —
From;
City C.leri('s OfGee
410 F,. Washington 5[rcel _-__
]” CiIY, IA—_224 —
Phone: 319-356-5041
Fa): 319-356-5497—..—�'--"
Ani-, cv�
7 Mille ❑Female I SZ ( _ `? - 3 7 (z,6'
IYalvel' lnforrlrp•IFolt: R'ilhoul a signed waiver from the subject of the request, a complete criminal history record may not
be roleasable, per Code of Iowa, Chapter 692.2. For complete erlminal history record info rin6(ion, as allowed by law, always
obtain a'p•aivcr denature from the
Wr1IVer J?eleaSe:IhcrtDy givepmhission for the abover uaslin
eq Bi 10 candaq an lv" uhninel history raco,d aback nvilh,pe Division el Clip,inal
lnresGpation (DCI), Any criminal history dale cmlcesnlog m Thal 15 melliNumd 6 IL a Dc
y y pleased as alldu•cJ 6y larv.
IdrolverSlgnnhue; _ __ _ \
Iowa C'rimina> Iistol ' Reearci r✓lleck Results — ------
(UCI ,isc only)
As o1 - —_ of the provided name. and dale of birth revealed:
No lova Criminal Hisloly Record found with I)Cl
W -J
❑ Iowa clinlinal History Record attached, D(,N) tl c7
D(A initials
lvj
_ _._- r �.•.
UCb77 (08/25/10) --------- -_.._.
Received Time Aug.27. 2015 2:24PM No,4323