HomeMy WebLinkAbout15-191� r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO.1 5— ) 9 (
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAS 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
1. Name (REQUIRED) �� �, >/ ( tv fuufcce 1
2. Address (REQUIRED) 2 U ti rs P-Tt- k. t(L1� 6e A' (5a;
3. Contact Information (REQUIRED) Email: (MJp Ov—(( I r c (} . - ccs
(All writte� comm4nlcan sent via email)
IN�J a. t �2 2,2-
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4a. Chauffeur's License expiration date (REQUIRED)' 22
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Cell Phone:
b. Taxicab Business Name (REQUIRED)
5 Prior experience in transportation of passengers: V --I
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Convicted Dismissed
Where
When
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Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
a
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended lead 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
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pr iW thlgme(4
—0 71
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT£ TI IED �-�y
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE t5F IEW + f
You must apply for an individual Department of Criminal Investigation Report (form available u�bn request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
(1-1
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
3 P _ 117 �1 issued on $-13-14 expiring on - � - 1'b - 22 . 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 9
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by F i k zY . J • I"\kAAn vim) : on this j day of
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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).
Expiration date of Chauffeur's license o 112 7 D 22
J't I +—' (`-i
Signature? Pohce hief or designee 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.
Signature of City Clerk or designee
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Office Use Only
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DCI report
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State certified driving record
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Aug 0. 2U 17 2 V 0 1 v of Criminal Investigation No 4816 P. 1/1
Fre..,—, .-. ..-w- --..y clnrl. `....,. -. -.,--- --_-.. OB/C./201S 16:1 ..187 /002
&I -ATE OF IOWA
Criminal HisfarY Record Check
1 Request Fovm
To: Iu'tva Division uI' Criminal Invrsligatin),
9lgsporl. Operations I3ureau, l" Floor
215 L. 71'i titrect
nes Moines, Iowa 40319
(515) 725-6066
(515)725-6080 Fax
Am
oil:
1)(a Account Number:
lif applicabic)
From; _Ci(y of Iowa Cid-_—_--- --V--- --
City Ckrlds OPfcc
410 L.. Washington Jilrcc(
lowszlA 52240
Phone: 319-356-5041
Pak: 319-356-5497— �'--
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Waiver rnfOrpialiDR; 'Without a signed waiver from the subject of the regucsl, a complele criminal history record may not
be roleesable, per Code of Iowa, Chaplet, 692,2. Nor co. mnlete criminal history record information, as allowed by law, ahvaps
obtain 8 wa(vei-signature from ehn Ruh i one �r th..r... —1
Waiver Reieto"e: I Lercby give pcnni5Si0n fartlm above relluesring ORmial to conduct
Ineesligalion On loq�a criminal hislop' rocOrd check �t4ih the nlvl$len of Ginfinal
(DCI), My criminal history dale cOnceming me that is maintained bylhe DCI may be released as allowed by law.
Waive, sigriafr)re:
Iowa Ur1_minal HistDrV Reccord Check Results =
As Of a search of 11)e provided name and date of birth ievef&:
NO town Crjuunal History Record found with DCJ
ED Iowa Criminal Jdjstory Record attached, ))Cl N
Received Time Aug. 4. 2015 4:36PM No.2286
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