HomeMy WebLinkAbout15-211CITY 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
a1C_
(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)
haiPure to c0rt2plste the "required" information will result in derriai at the afypflcatron
1 .• a
Last ,
2 Address (REQUIRED) k 5 1 H A 0EY Rye Tnk j L',41 P, S? u (�
3 Contact Information (RF,QUED) Email: MDaq�py 2a�Pya�1Po C0�
eIlPhone:
. 3 l�LSI`2�� I
(AII written communication sent via email)
i
2eob (P Ya t' ��
4a Chauffeur's License expiration date (REQUIRED) "R 12gi Zd is,
b. Taxicab Business Name (REQUIRED) �SkIaA Vv CA 6 �nn7VLQv(Cay) Cora L I+ t' CC'
5. Prior experience in transportation of passengers: tt 6 y/ J, w* y[ >
i
& Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? AZ
Type of offense Where When
What happened to the charge? (Circle one) ,t/v
Convicted Dismissed Deferred Suspended Plead Guilty Other A/-0
7. Have you been arrested 1 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 � A When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) OVO
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 Department of Transportation a v lid Chauffeur's license number
__Li 2CL�9 issued on 4128 Ii r expiring on o[ 129_, 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 &A 6 IL -----
Date_#L S
STATE OF IOWA )
COUNTYOFJOHNSON
Subscribed and sworn to before me by U n &r,n. S cQC S on this day of
1 have reviewed this application, DGi 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 Chauffe license
Ll 1
Sign ture of Police hief or desi 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.
�?Id C
Signature of City Clerk or designee
` Da
tb
aafwrrXIDRURADG�PPL92m4a1elded.00c 03/2015
Vl
Office Use Only
Approved application
r__
DCI report
r r;
State certified driving record
Website update
n.3
c;-
aafwrrXIDRURADG�PPL92m4a1elded.00c 03/2015
D=m
z
3
3
a
a
z
ET'<
o p
mho
m
6
3
o n n
F10
n
y
Nj
app
a
b
�•
n
�
r
➢
➢
N
rn
O
D
D
N
if
-
m
m
_
p
Vf
A
A
p
.l =0
Ot
D•
a
U F
A
V
A
V
r
0
O
O
a
O.. n
�vv_
�0
x
d m
a 9
�
n
N
a
Iv
r
n w
rt±
C
<
a
y
a
a n
e
C
N
oG
3
Z
w o
o
�n
O
•-
rye
i
ai
a
mlu
A'
a3
C»
O
p
�
o
to
j N moi.
CL
y
Trop
0
rIt
�a
a
Sys
CLQ
p
c N
O
maw.
m wom
p^ o
En X
n n
n
4 7
n?
c m
°°
O
r°
s
9
�
a m
m 0
UI y
C
m
m
O
C c
a .Z'
S
^
Z
Z Z
Z<
Z
A
T'"
a
o
p
o p
o p
p➢
p
r
p
p
w
w
m m
c "
c
m
m
� o
n
a o'
c �
� p
0
N �
a m
Q 'm
� n
p
�n
p m
May. 8.
2015
2!52PM
Div
of
Criminal
Investigation
No, 6804 2,
9/17
FYu rn:�ny
or iowea „ny
Clerrc urncq
he releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by laiv, ahvayr
aiaa :aoesc¢av
os/o6J2o�6 1T.G3 11066
P.002/ooz
VpY bKpayp,
l• s,
�IOWAte;
H1DJY:li>�0 �•
STATE OF ROWA
C9°1i1nina@ )EI OaTsy Recwr'd Check
]kegmestf Form
To: Tovta nivisia�i of,Cl_irdiaal Investigation
215 street
))ES IAolnes, Iowa 503]9
(5]S) 79,5-6066
(515) 729.6090 Cas
._ Y_..._ Dom, —A r'1-1. nw
DCT Account Number:tioU)
(ifnpylicobla)
From: Cityorlowaii4y,_
410 F. Washington Street
Iowa City, fA 82240
Phone: 319-356-5041
Pax: 31956-5497
Last Narne (nandatory) First Naine (mudalory)
diddle Nalrle crtcom nimded)
J 1 l S KC) DC7 d-& \,Y
Social Security Number(iecanrmai&d)
Date of Birth (mandatory) Gender (mandaro )
d 3 — U.5 — S8 Tale ❑ Fernale
%6- S g — !• b
Waiver Infiormatlow Without a slgned waiver from the aabject of the request, a complete criminal history record may not
he releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by laiv, ahvayr
obtain a walva• signature from the subject of the request.
Waiver tie%ease:) hereby give permission for the above requesfng off tial In rnndad an lows criminal i)wory tccord check vilb the Division orCrimioal
bn•eaiption (bCO. Any arimiael history data eonarning nm 11191 is maintained by the DCI may be released as Dunned by Ian.
Waiver Signature:_
Jolva Criminal fligaL &c Citeck Results (I)CI we only)
As of 5 �6 S , a search of the provided name and date of biah revealed;
No loa;,a Crin]jnal History Record fotuad with DCI = ; 0
g) ' -O
Ioara Criminal History Record attached, DCIS
r r•a
DCI initials��-=-' L
DCI -77 (08/25/10)
Received Time May. 6, 2015 10 57AM No. 7224