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HomeMy WebLinkAbout15-261E r , al► � � CITY OF IOWA CITY 410 Cast Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) . IDENTIFICATION NO. `�r- -z- tv I (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review mint 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 3oS Sa, Middle �►�Y "o1V }�awtkrS Sr. ZowC;� G fy _Y4, 3. Contact Information (REQUIRED) Email: A/ r� Cell Phone: (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) +'4 Z -3 - Z©) b. Taxicab Business Name (REQUIRED) _ 315- 4-7 f -73.15 5. Prior experience in transportation of passengers: line: rs CV ry r r C CCir) 3 ti 1 - -� 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offensen e 1 Where Wh �c�SS. Co'1�r}I .Sv�iAVfr_q 11 14 j 7 What happened to the charge? (Circle one) Convicted '� Dismissed Deferred Suspended Plead Guilty Other MAR t 7 2011 Have you been arrested 1 charged with any traffic offenses in the last five years? t�5 Type of offense Where When lo What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? I - i Two of offense Sp..0rr I* Where When 2 l-m,,,_Q 40 COL -10t , S i 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 nn 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 valid Chauffeur's license number so 2 K# � ci i d–(n issued on 6U 1 expiring on I understand that If I falsely answer any questions in this application, that this app ical ti6n may be denied I a ree th t 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 al[ times with all c° the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant �O1Mr'l 1Q `>�� Date—3 STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me byn t Q�� )kE S on this / 7 tik day of •f1n- r, S. 11-�rC I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that the e-1 information which would indicate that the issuance would be detrimental to the safety, health or welfare resider s -fife L�yty of Iowa City (Title 5, Chapter 2, City Code). VI7� r MAI 172015 designee I ji 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. THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR. Signature of City Clerk or designee D e #N44Y4+#*xt5'%T1k#*#*h*xxkrtrtxxxx'rts*xx#'*k*44##fix'fiNWNfiP'#'kPx"kA-kAA-kt#A;AxY+e*k+#xf1TxT;x*T%+Tkx;W+ThMfi##***x*#k;#*#**x#*#x#4 t A A AlA i A: Office Use Only Approved application DCI report State certified driving record Website update Cl.lk7AXIDRI,BAWEArrre�m 4ercaiM^.d DOC 01/2015 Ctahn of 7nwu Till in all shaded areas. Requesting an lows ci iminal history record check on: Last Nawe.gpei Ifu(manda[nry) Mrst Name Middle 1, NoF?tbje (recmimended) rTom+.,JS D.7'�V(f) pt,�Xi atv SP Date of Birth Fenw A4,oimaerta Irnandafory) Gender Omenn (ma cdatoiy) Social 'Security Number !t'econunended) 11-31s-6 Male ❑ Female waiver Sign attire rip rrra(if the request l 9 on your self. please sign it the r gnral it on someone elae,wuteN/A_) Results As of tz 1 5 ` , a name and date of birth clieck revealed: �] No record found ❑ Record attached DCI # nr, f ; :+; i 14.rd Receipt Number of requests ( x $15.00 per last name =Total amount $ 1 S. b O Method of payment: x cash money order check # Cardholder's name DO initials Credit Card # DCI -83 (09/09/10; Revised 10/ 1,110; form reviewed 08/ 11 / 14) Exp. Date VIIIuiF ONLY MasterCard or Visa (Lrsf 4 digits) | E� § k_N �)).G - - § d = k ! [)))( �.��jj�cm §:\}\~ . e w;v03 ) / } k! ! + _ � §c E k | ��!■!, \ kc � \ } \ � 5 — \ \\ \ \ \ \� � k . } � | E� § k_N � - - § d = k ! | E� § k_N - - § d = k !