HomeMy WebLinkAbout15-209CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. l5-- a C�Q _
(Office Use Only)
APPLICATION FOR TAXICAB I 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
Middle
1 Name (REQUIRED) Mp
2. Address (REQUIRED) k5 I q R hey R ve TsJ)G,{ A S2 Z
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3, Contact Information (R QUIFjED) Email: M uaqc�J „@y ZYg�lao poCell
l Phone: 3 ISI_ �129�
O ,Lr �, (All written communication sent via email)
ezn06 co ye, 1,ad
4a. Chauffeur's License expiration date (REQUIRED) a IS
b. Taxicab Business Name (REQUIRED) ,tjIA VN C4A 11'",V\A&(C6[tel Cvr� C( i CU
5. Prior experience in transportation of passengers: t cC), C< o) tw* v y[ >
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? kl- j
Type of offense Where When
What happened to the charge? (Circle one) AI -J
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested I charged with any traffic offenses in the last five years? �L)
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 prtMddthep ame /v0
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATi=',t ATl'D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE (°AEF REVIEW
cry
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
her certify that I have issued to me by the Iowa Department of Transportation a v lid Chauffeur's license number
1�4i 1l_�`=� S issued on 4(1291i ( expiring on )2V2 1 understand that if 1
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 An �6 �z Date L
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by M c� OLn� rS 1 �6 i _e, on this T day of
X Z)D 5
♦°�'vJ
WENDY S. MAYER
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My Co mi 'on Expires
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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 Chauffe g license
Sign ture of Police hief or desi ( ate
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):;<.
Signage of City Clerk or designee
Dat
Cler AXIDRNBADGEAPPL92014amended.DOC 0312015
Office Use Only
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Approved application
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DCI report
State certified driving record
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Website update
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Cler AXIDRNBADGEAPPL92014amended.DOC 0312015
May:
.8.
2015
2:52PM
Div
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\ CrllFu➢VSTATE OF RO-VVA
pO HisteryReco.ro7 Check
Reqne�t Form
To! Iowa �bvrsag�i of Cgtminal Luvesti�atcou
215 I:. 9'a street
Des Moines, Iowa 50319
(51S) 725-6066
(575) 729.6030 Cas
I am,ennnclnia an Imvn C-ri in incl Hisrm•v Rennrd Cheelr no,
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T3C:T Account Diumber: -_ �-lt�l7��
(if applicoalc)
Frail: City of fuwa Cicy_,
410 F. WLshingtoo Street
fov/a City, fA 52240
Iahooe: 519-366-6041
raa: 319.356-5499 _ _--_---
Last Name (mandatory)
y,•irli Dame (n)andalory)
Middle Narine (feconintended)
Date of Hirth (mandam(y)
Gender (mandmo )
Social Security Number(recan,>rendm)
_
03 —Us— 5
�NTale ❑ reDtale
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Waiw I%foi-matiow Without a signed waiver From the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as Allowed by law, always
obtain a waiver signature from the subject of the request.
Walper Release, ! hereby Eivt pcnnission for the above raquesling offr:ial to conduct m lora crhuinal hislaryrecord check with the Division of Criminal
Inresligalion (DGl). Any criminal history Bala caneerning media is mainlnia;d by the DCI may be rcic4sed as all owed by law.
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Wa[I%eY S;g%r[tNf e: !" �O C'� �• W
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As of _ �w SS , a search of the provided Dania and date of birth revealed:
PNo Iowa Criminal History Record found with DCT
Iocara Criminal History Record attached, DCl #.
DCTinitials� )k -
DCI -77 (08/25/10)
Received Time May. 6. 2015 10:57AM No.7224
(DCI use only)
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