HomeMy WebLinkAbout15-193r IDENTIFICATION NO. f 5J—�
_ 1 (Office Use Only)
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APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(319)356-5040
(319)356-5497 FAX
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1. Name (REQUIRED) First
M Last re
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email:'tf,A1)ttUelZ =l if 4t` )i�U. 141 Cell Phone: LV9-4dO-a-41
(All written communication sent via email)
4a. Chauffeur's License expiration date (R
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
TVDe of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? /U
Tvpe of offense
What happened to the charge? (Circle one)
Where
When
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? Ajo
Type 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 ne_61 e(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE ;MFI&D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CW- RE
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You must apply for an individual Department of Criminal Investigation Report (form availal ,,, . it requ
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(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY]
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02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb ert
cify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
7 L ' j5 /� issued on t7"d %'%� 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 41r,0hJ Date 'afy
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 1:�V_6= � h . &LA k-. on this 19 day of
Saga#. d nt
1g,&I
WENDY S. MAYER
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My Explrea
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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),I/ ^^����
Expiration date of Chauffeur's license 61 6,1 ^'
Signature of PICI60K designee
017 l0- 2-o
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.
Signa e of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Date
ChNTAXI DRWUADGE PPL92014amended.DOC 03/2015
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ChNTAXI DRWUADGE PPL92014amended.DOC 03/2015
Aug,31. 2015 2 : 3 1 P M Div of CmiraI Investigation wo.4522 P, 4
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4uppul-1 Qpera(iuns Hureau, 1" Rinor
215 !i. rya,'wee(
Des Moines, Iowa 50319
(515)72S-8066
(515) 723 -LORA pax
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Date of Birth (maul
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DCa Amount Nmlillea':–
lifapplicable)
Rana:
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4? fl E. Washington �try
Iowa CI(�, 1A 52240
Yhunc: 319-356-5041
Far; 319.356-5497
cg ale ❑I emale �aJ � J 6 y C�'�p�v �
Waiver Inforfrrnlion: Wilhoui a signed waiver from t4esubjec(— of the request, a comple(c criminel history record may not
Ile releasable, per Code orlowa, Chap ler 692.2. For co(, nnie(a criminal his(orp record informstiimi as a islori re lax, ahvays
obtain a waiver si ncmre from the slsb'ec( of the rcuues(.
"'alver Release'.) hycby give permission for Ile Abe
.'eu uc lin ofOcial to
hlvca4gaupn (DCI). Any erimbiel hiamry dela Comming nx the9ismel9lahltd by 11 c DCI may ac tele sc4
Zi)ftdW en 11Lsiallo, edsrecord
by cjlcok a 14 lbe Division of Cri"'final
fvdver Sipla frtr•e:
.iOW2 Crilllilla) HistOr R–e—c-o d (hCCla RCSllIt6
As of �� (�
{U(:I list
pllly)
w Y a search of (he pypvided name and date of birth
revealed;
leo ]oufl Criminal ljisiury Itrcord bund with DCI
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1pvva C:rinlinAl History Record Mlached, DU i!
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Received Time Aug. 28 2015 8:41AM No 6657
C4'10WAD0T Jovvadotqov
SMARTER ! SEhtPLiF t CUS7Qfl'sE DRIVEN' . YUifVw
Offir_e of Driver Services
PO Bost '3204 7 Des MMomss, €A 30'WC-9204
Phone: 535-244-9124180632-1121 1 Fax 515-239-1837
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Certified Abstract of Driving Record
Inquiry Date:
8/20/2015
DL/ID 7F:
353AE7542 (]A)
Customer #;
5527582
Name:
Barner, Frank Melvin
Class:
C
ID Status:
EXP
Address:
2207 OAKLEAF ST
Audit #:
5638937
DL Status:
VAL
Issue Date:
11/18/2011
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration
06/19/2016
CDL Cert
None
rn
522411366
Date:
-:-
Status:
c
Endorsements:
NONE
CDL Med
None
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Status:
Mailing Address:
2207 OAKLEAF ST
Restrictions:
Corrective Lenses
Restriction
None
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Date of Birth:
6/19/1967
Supplement:
Mailing City/State:
CORALVILLE, IA
Sex:
M
522411366
History Information
CLEAR DRIVING RECORD
Name: Barner, Frank Melvin DL/ID: 353AE7542
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:
:.1..��.l!..;r`/,pay
8/20/2015
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IOWA
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IowaDepartment
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Name: Barner, Frank Melvin DL/ID: 353AE7542
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