HomeMy WebLinkAbout15-185r I l 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO.
(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
First Middle Last
1. Name (REQUIRED) 'r0.}Ita , jS NN
2. Address (REQUIRED) _ 3a1 �)fhP e- 44
-
3. Contact Information (REQUIRED) Email: 9C t rue l lol i w c -c_ ,w Cell Phone: 31q 32 3 - U 6 �0
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 09— 1 --;L - Z(] 1 5
b. Taxicab Business Name (REQUIRED)_ yoow C"
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?v
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? N 0
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
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
5' S'D µ issued on O C ulbxpiring on c)9//�-/IU/S. I understand that if I
falsely answer an 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,SAapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date ,':�L'?y�c�-oy5
STATE OF IOWA )
COUNTY OF JOHNSON 1
C
S scribed and sworn to before me by �`7� �� � C �� on this 2 1Sf day of
t 5
KELLIEK-TUTTLE i�� C_(r
i n?lumber 227819
nr'slon Expires Notary Public in and for the State of Iowa
*R**********k*k*kk***k*********************#*********kkkk*k**********************X**************kk***k**kX**k************************k*XX*k*****
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). /)OZO
Expiration date of Chauff i ense C
Signature of Police Chief or deQfhee 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.
I W ?k� . --ealfV
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Cl.,rw IDRivenocFAPPL92014d„re,ded.DOC 0312015
5'
Date
Cl.,rw IDRivenocFAPPL92014d„re,ded.DOC 0312015
.Aug.21. 2 U I ) 9:I5AP1 U I v o' GrlminaI fovestiga?loil Co. J ( U y r. I/t
F..,....... — ,.mow.. ti„y — oe/20/ao16 16:1v *22, r.vv2/OG2
','i'FATE OF IOWA
C'I- iIffilal Mgtor-5/ Refxjr•(f Check
Regnest Fewin
l
Iowa 1)it, isIon tiI'i:Yimin,I lnvestlkaii0u
:IupportOpel, ationsB resp,f"Il[nor
E, ?'Istreet
lies f,10i11es, Iona 50319
(SIS) Tr,S-6666
lasts) gas-suao rak
Check oil:
DC'1 Acth;unl Ntfwber
(if applioeble)
:—it
City Clerk's offs _-
aiU F,. Washin lOn 3trecf
3owa lily, rA 52240 •_-,_._._�—
Thune: 319-356-5041
Irax: 319-35ti•5497
Date of Birth (mandator)) --
sender (nimdelopl Seciat St
ecuriY Numb'
i) � — U � `-=l � � ®1�91C ❑1.''001910
larVEr' IJrfot"Maliolt: Without a signed waiver from the subject Of the request, a complete trim nal his o 1 record may not
Ube releasable, per Code of lo,q'a, Chapter 692.2, For tom tete criminal history record information, es allowed b), law, always
obtain a wai� Vie(• Sp.,tare from the sub'ect o[ the rcyuest.
Wafver )Zele(1se: I hcnb
give pcnnis4 on for the above regn:sling Official to conduct nn lu rvn criminal Iliz�opvccord chCCk lvllh the Division ofCrn
lnresliganlon (DCI), A iY criminal history dote ewlcemilig Me [bat i5 o,611amed py Ibc llCr nla hs
nal
9 released as allo\ved by Ima.
Witiver
N\c�-t Pmt
�eirrrinaicytor �bee�rd Check Resuft5��.-- -----
only)
As of � II((
--- 1L� searcl, of the pro vidtd name and dale of birth revealed: (Dia nae
No Igw,t C:rilltinal l-Iistnry Reeord found „pith llCl � 1
tr'i'g � 't •'I'i
Iowa Criminal History Kccurd allached, 1)(.'.1 # `J
Dcl initials ` 1
.-.. _. —--.--------------
Received
---.._._
Received Time Aug.20, 2015 312PM No,6042
W"10WADOT
SMARTER I SIMPLER I CUSTE NIH DMEiV �+?t .Bt�4"ft��i��. QiJ
Office of Driver services.
PO Box 9204 i Des Molnes, I.A 5-0306-9204
Phone: 515-2448124 C &30-532-1121 k Fax- 545-23J-1937
ww.v. iawado€.gov
Certified Abstract of Driving Record
Inquiry Date:
8/18/2015
DL/ID #:
754YY5104 (IA)
Customer #:
3857305
Name:
Churl, Gatluak Deng
Class:
D
ID Status:
None
Address:
321 FINKBINE LN APT
5 Audit #:
9348333
DL Status:
VAL
Issue Date:
08/18/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
01/01/2020
CDL Cert
None
522451707
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
321 FINKBINE LN APT
5 Restrictiori
NONE
Restriction
None
Date of Birth:
1/1/1983
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522461707
History Informatirn
Convictions
Citation Date Conviction Date ACD 0aplanat€on County JUR
10/07/2014 01/14/2015 M14 Fail to Obey Traffic Sign/Signal :Johnson IA
Name: Churl, Gatluak Deng DL/ID: 754YY5104
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:
�_: '••••'••��/d; 4r
8/18/2015
IOWA ' ¢
,+r
4
D. O. T.,
�_,,� ''J,
j`s
ram=
R
P, ""•'
RRIUEA,_=
Office of Driver 5ervlces
"I
Iowa Department of Transportation
Name: Chuol, Gatluak Deng DL/ID: 754YY5104