HomeMy WebLinkAbout15-217CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1926
(319) 356-5040
(314) 356-5497 FAX
1. Name (RECD' IRED} -
ID EN`r(FICtATION NO. _-)5-.�) �7 _ _
(Office Use Only)
APPLICATION FOR TAXICAB t MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
First
c 0?a71: _ iI PC�p i?,C ,. �_1 � ._,..ir ri...i(i'-R+, f l Gl Fi TiSt� i,.4.. f, fir;
2. Address (REQUIRED) ..-.._._. I--
3. Contact Information (RFQU[RED) Email:.�4
, --
4a. Chauffeur's License expiration date
b. Taxicab Business Name fREQIJIRFD)
5. Prior experience in transportation of asson ers:
6. Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsewhere?
eeoof offense Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
When
Suspended Plead Guilty Other
7. Have you been arrested 1 charged with any traffic offenses in the last five yaars?
Type of offense Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
When
Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
lyp of off_anse
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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Dejpartrnent of Transportation a valid Opauffeurs license number
4' G°5 issued on Ci expiring on may, I understand that if
TV falsely answer y questions In thls 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)
11
Signature cafApplicenC r
_�`~y�^p,�.y�___�__,___. _ Dafe .`��
Mi*hkkk:FkkR%'A%JckAs**[�eRfNLk%4%MkWR*WYY*q%*NY}*IRYNµ N*Ni RhMY6NY**NMMk'µNN*iy�lMY.J4*'R'MY*}*k RY: Y*I: tl'FNS%RRR:H: µkk4*hhNN#MN�V nWhvM%MN%RRk*kH#MkWY
STATE OF IOWA )
COUNTY OF JOHNSON I
e
ubscriberj and sworn to before me by (,t-( t-
.�`�'?�..,as�_�i9?'�`�` �.'� on this _day of
*R'1{*RkMIM µkRRkRtXRbl4}*MXki!}'Y1�*nRRRR}Y�Rtr*MMy4CR}RfXk*RN NNIMR#Y*XRiYM01fXR8kMM4%iN i4FMiYXAAM}M**RXkWMkk}1RAARRI!*µYkMXk'kkkkRRrrtikRl�kWM}MN khP
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the Issuance would be detrimental to the safety„ health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Signature f P ' Chiof or designee
Date
AFTER APPROVAL BY THE CITY CLERIC YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR.
Signa a City Clark or designee
Date
x%*TRM** �xxhkPx*+FWMK*lbxhAkfeW**RA*N***-kµRRNkMM*R**R**kHf:Nyy:f*y*}%AAM*E'knµ**th**MWIFk HRkNHkxixy-hMNYµIVthM14M#xkYFYk**%fYWf.L}M*}}klii
Office Use Only
Approved application
DCI report
State certified driving record
Website update
GkWAXIDRN MjGEAPPL9A11 r., &DOC 0212015
Mar. 2. 2015 4:12P1 Div of Criminal Investigation No, 1480 P. 4/6
J.7uin w.ly Vrc,n oltr al Iowa b ly 1t9. 7D67 F.
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STATE OI 1D +1' Ifll
2dirninal History Record Check
RequestForm
To: %wa 111rrlrl0h of criminal Lrredlgadon
Support Oparatlona Sul 62u,;°$lour
215$, 7,h6ti eet
Deg Mama, Iowa 50319
(919) 723-6066
(515)7254080 Fax
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Fromi City off Towa CeIty
City Clerk's Opflra
410 X. Washington Street
Iowa CU9, U 32260
Phone; 310-356sM41 _
1hxt 919,960-M'497
there orexusle,
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Wo[verXrajaranmYon: WULontasgwwaparftmthe subject oftherequest, acomplete crlminath&iaryrec il oawynpt
beroloasable, per Cade 61Xowa, Chapter 6912, For OAWftC crhnlnal hlrtory record information, as allowed by law, always
obtain awalverai ature*Qath0subjectofth5rennest.
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6 ae M of the pro -ended na= end dato of bilthrevealed:
,No sown CiiMfUl FTistory Record foUnd Wfib ACI `
® Towa Criminal MstorY Record attached, I)C1 #
DCTiniti*—A-1=--
Deceivedl me7rFeb.2T4)015 3:47PM No. 1415
SMARTEW tIMPUR I COTOMER MW ,,,.wwwJowadotgav
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Certified Abstract of Driving Record
Inquiry Date:
3/3/2015
DL/ID R:
413AF8068 (IA)
Customer A:
5597450
Name:
Bod]ana, Bassal lean
Ciess:
D
ID Status:
None
Address:
431 5 SCOTT BLVD
Audit Sf;
6640514
DL Status:
VAL
78/03!2014
�I0/3012014 `�.N50
Imus Date:
01/24/2019
CDLStatua:
None
city/State:
IOWA CITY, LA
Expiration
12/31/2015
CDL Cert
None
522455526
Date:
Status:
Endorsements: 3
CDL Med
None
Status:
Mailing Address:
431 S SCOTT BLVD
Restrlctlamn
NONE
Restriction
None
Date of Birth:
12/31/1985
Supplement
Mailing City/Sha: IOWA CITY, IA
saxi
M
522455526
Mlstory Information
convictions
:Itation Date
Conviction Data
ACD'
Explanation
County
IVR
10/26/2011
:11/28/2011 _
M14
Fail to Obey Traffic Slgn/Slgnal
0ohnson
JIA
37/13/2013
08/01/2013
_S92
Speed
IScoti
EIA
78/03!2014
�I0/3012014 `�.N50
�Lnproper Turn _
Ilohnson
Accidents - Accident involvement Indicated does NOT mean the individual was at fault or given o citation.
Accldent Date
rase Number
1DR�
iA.._.
J8103/2014
,810536_
IIA
10/13/2014
.,821595_..
'Ik
Name: Badjona, Basal Jean OL/IDs 413AF8068
Pursuant to Iowa Code §321.10, I, lam Snook, Director of Dince 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 of idai 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 mused my signature and the seal or the Department to be set upon this document, at Ankeny, Iowa
this date:
iT•' 10 3/3/2015