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CITY OF IOWA CITY
410 East Washington Street
Iowa City. larva 52240-1826
(3 19) 356-5040
(319) 356-S497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. 5 -
(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
2. Address (REQUIRED) 2xr,2 Rj) Apt -20 /oy„cr ;g rt3 5 2 2%L_/
3 Contact Information (REQUIRED) Email: (f� Cyn z,V _ c... Cell Phone: 3l G 5) Z 9 2:71,
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) n 1 / 0) l 2c 2e�
b. Taxicab Business Name (REQUIRED) _/J172;,fa l t„ )�
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? ilio
Type of offense Where 47/=
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended{stead Guilty )
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
Other
When
Convicted Dismissed Deferred Suspended Plead Guilt 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 provide the name(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT TIAD
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE-, EVIRMEW,
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You must apply for an individual Department of Criminal Investigation Report (form availa��ile upon regrfest .
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY}73 N p -s
t�
`•••,+ 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
f� r 2 � � issued on J 5,j5 expiring on i . f . 20 I understand that if I
falsely answer any quest ons 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 _5,;P� Date 09.03,15
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by .�paJ) X IC AVi 0+-1 C(5k,, on this __Z�l day of
WENDY S.
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 000k l 2u20
n b9c,3(,C�_
Signature of Polic6 Chi f or 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.
SignOW- re of City Clerk or designee
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Office Use Only
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DCI reporter
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State certified driving record
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410WADOT
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Inquiry
Date:
Customer
Name:
Address:
Office of Driver: Services
PO Bax 5?03 1 Des 4'.oinee IA SJX,;3-92G.4
Phone,- 1800-,32-11-1 f Fa:;: 5.5-239-'i8w7
www.ic:
Au;.20. 2015 10: 11 AV Div of Crino n a I Investigation
of four. City Cl.rk $19 3666497
N , 4084 P. 1/2
08/26/2016 l3 -4s L227 P.002/002
'ri1Y1iII I }'Iist(1r r Reetlyd Check
Requ"l Form
fo: lolva Divieion of Clrilrllaul Ulvesligalion
$appal'( Operations l3orcau, (" Floor
21.5 L. 70' Street
Dns Moines, Iowa 50319
(513) 72S-6066
(513)725.6090 hax
I am requestille an
/•�hodj ,rcS/ r'-,
01`01- )963
Record Check on:
Firs! Name (roan
5'7m eee-
DC) Accoiinl
l i1 appliop6lej
Vr(iln:—
Cily Clcrlc's (YfPce------ -
.410 E. Washington 3trec(--
Iowa City, lA, 52240—�.__.
Phone: 319-356-5041
Fox: 319-356-5497--'-.�...._�__..-- --
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227 91 92) 3
WoNet• XSforntef(ioltf without a signed waiver from the subject of (he request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. Tor com tele criminal history recard information, as AoNvad by law, always
obtain a waiver signature from the tuhiarr of 11,4 rm..e,..
Waiver Release I kir 6 . i„�
Incesdgalian (DCI).
Any criminal bisiol)ory dais ton for die wave reyacsling of&tial Io conduG an Imca criminal hisieyy rosartl clrccN ivitN tlic nivisa+n o1 Crinlilral
data couaming me 1118! is maiulained by Ilm DCI may 6e rdeased as alloWrd 6y lair,
Woriver sib rl attrre;
Iowa �1'ifrtirlaf �%is��r �ecarc� �F1eck Results ----
- --- —__
(15CI use pnlyl
As of
of Ilia provided oame and dale of birth rcve;jled:
No Iowa (:'rinlival 11ist(513, Record
()iminal History Record attached, l)C'141
Received firoe Au v. M. 7015 I:41PM h'o-616R