HomeMy WebLinkAbout15-188no
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. I !�-- I E55
(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: } xM Cin h Orr,/cQ"ll Phone:
(All written communicatio ent via email)
4a.
b
5.
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)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested /charged with any traffic offenses in the last five years?
Type of offense Where When
What happened to the charge? (Circle one)
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
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 pro ft(te 6 e(s)"71
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE 604TIFIED M
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEFREjtEW 1
a
You must apply for an individual Department of Criminal Investigation Report (form available upomsrequest).
�y
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VE=HICLE DRIVER
Page 2
I hereby certi that I have issued to me by the Iowa Departmegt of Transportation a valid Chauffeur's license number
i ;� �y (Zi�� issued on %/, 71z�x�tring on �] �1�. I understand that if I
falsely answer any questions in this application, that this app/ catio may be denied. I agr a 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 f Title 5, Chapter 2, o the Ciity�Code.
(Needs to be signed in front of a Notary Public)
Signature ofApplica[JCJrtL ///, CSCnX4�� DateQ`
�.
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this �_ day of
wENDY s.
Public in anolor the State 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
Signature 00, hieor 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.
�,) 7e. ��
Signatu f City Clerk or designee
Date
cleddrA IDRIYDADG64PPL92014amennded.Doc 03/2015
Office Use Only
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Approved application
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DCI report
State certified driving record
Website update
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cleddrA IDRIYDADG64PPL92014amennded.Doc 03/2015
Aug, 28. 2015 10:18AV Div of Criminal 1nvestlgaticn Ne4348 P. 102
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C1-i1nillal flk(ou Ede( -Ord Check
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Request Form
Tu: Town DPoieion of Criminal Inveslira(lun
9uppUrl Opera(imnv Blo mu, I" Einar
215 i:, y'° 5(eeet
Des Moines, 10e1.2 50319
(515) 725-6066
(515) 92S•P,09f1 Rax
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410 E. LVashing(un Soce[_-._....__.____„___
]nwa C'i[y, IA 52240
Phone: 319-356.504]
riex: 319.356-5497 ---.._.^—_----_-
Iowa Criminal History rd Check ResultsAs ^
01— a search of the )n'ovided name and dale of birth rn;ealzo
No lows Criminal Histo)'y Record ibund tyi(h BCJ S -
lows Criminal History IZecard attached, 1)(,I fl
DC) initials
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Received Tine Aug, 21 2015 8050 No, 6552
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