HomeMy WebLinkAbout15-189��..®4I.
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) -
IDENTIFICATION NO
8c.
ffice 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
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2. Address (REQUIRED) t'7/-? n by /6z--�a U2�( , 1 y S ZZ /
3 Contact Information (REQUIRED) Email: Ka me ll4;r�a (-' iqw aA -w -., Cell Phone: 3i 9-S 12,- &- 4 3
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 01.QI' mol
b. Taxicab Business Name (REQUIRED)�c">r-v�+n } G�Cr --Ctit�
5. Prior experience in transportation of passengers
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6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
P1 D
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? YD'S
Type of offense Where When
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred SuspendedPlead Gufl Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? eN d
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prim thaame{s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATECURTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF F4/IEWn
F `.s
You must apply for an individual Department of Criminal Investigation Report (form avakable uxh reg6tt).
c --
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) `c'
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Depart ent of Transportation a valid Ch uffeur's license number
,n",5 %}% S��2 issued on 0 0 'I expiring on 61-,0/ �t 4. 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 Tle 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date 0?'6 20
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this ( day of
and f¢r the State of Iowa
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 I to ( I of /?,D, t
Signature of IV
Chief or designee
o /0( LT
Dale
AFTER
a e
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 off City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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FAX: 515-239-1837
History Information
Convictions
Citation DAtb
Certified Abstract of Driving Record
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Inquiry Date:
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Name:
IO status:
Adtfret,s:
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1,
OL Status;
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2
Issue Date!
Cot States:
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ExWrAflowl Dates
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EA,dvmewients:
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Maillill) Address;
2-13.1 RestrictIbn%:
NONE
ResAdOton
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App e 2
supplement:
Date of Birth;
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Maiiin
[A 5224E Sex:
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History Information
Convictions
Citation DAtb
Conviction Data
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'I'n: lnn�a niviSlon (if Criminal inveWl aHou
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Des Pill s, 10w•d 50319
(KI6) 725-6066
(515)77,5 -lam Cao
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('I applieable)
Prom: City (If Iowa City
(V Cler "(}ffcu .__.._...,._...... ___----
4.iC1 E. Washin (on 3(reel
to Cil fA 52240
Phone: 319-3365041
Fax: 319.356-5497 m-------.— ----
Record Cbeck on: _
Mrsl Name (manaalor))
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Gender (mandalop')
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rr ul [nJorntaf oil Without a Signed waiver from (lie subject of the request, a complete criminal hisfory record mel' not
leasa
be reble, per Code of ioaa, Chapter 692.2, For complete criminal history record information, as allowed by lavv, ahvays
obtain a rvaivers ncfurc from the subiecl Of the request.
;Vaiver llelertse t ¢rrh
fur Invevigehion (pCl). My giminalhlsla rdale be
abm¢ i rflrintsling olliciel la conduct w larva crirniusl hisloqrceord cheek wi@rhe Uivi:ion o(frimiiul
S h s is maintained by the UCl maybe «Icasaa as ahfoWcd by law.
As of
Ivailrer• Sional e:
No lo,vll Criminal 14is101y Record found with Di
❑ lo„'a Cliroival Hislory keuor('i attached, 1701 it
I)(:1 initials l�1—
6)(;1.77 (0b/21110) _
Received Time Aug 26, 2015 9:12ANI Aio.6662
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