HomeMy WebLinkAbout15-255CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(3191 356-5497 FAX
IDENTIFICATION NO. i J LJ 7
(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
.• o
1. Name (REQUIRED) Jo/1 %--e-ti!Ia-
2. Address (REQUIRED) & 5 IV&s. h
3. Contact Information (REQUIRED) Email: jyo �L }� /A-h/nv ,CAI, Cell Phone: 3%7
(All written communica ion Ont via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in bus
transportationR of passengers: 4�� 41 u e� 4: 15 .ang(
(
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? ies� N O _
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead�uilty Other
Have you been arrested/ charged with any traffic offenses in the last five yearsr iv v-
Type of offense
What happened to the charge? (Circle one)
Where
When
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? D
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prawde
.; r -r
cam-+, — :�.:�,
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE:&RTIP @D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE Cklllt , REVIEW
--...,
You must apply for an individual Department of Criminal Investigation Report (form availab!6'updj�requestj.
e �
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I here certify that I have issued to me by the Iowa Dep rt ent of Transportation a ali Chauffeur's license number
`� 3 L Z 5t 3 issued on as �.� expiring on I understand that if
7 p 9
falsely answer any questions in this application, that this a plic tion may be denied. I a re 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 t /4L& Date y D S
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 3a r K , T) u lLr on this day of
acts VJENDY S. MAYER Notary Public in an or the State of low
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-. `( 10 �
Signat o Po ic� f or designee
Date
AFTERAPPROVAL 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.
Signatur—e of City Clerk or designee
ate
Cie,kr IDRiveaDGE PPi92014ameodad.DCC 03/2015
Q
ngvr.X
Office Use Only
--i
W
Approved application
''µ'i
a
t
DCI report
`""
r--Y�p
State certified driving record
r
Website update
o
Cie,kr IDRiveaDGE PPi92014ameodad.DCC 03/2015
C
Iowa uGpartment of Transporta'tion
M. Services
ce of Dtlyw (rail Ffft) OW -532-1 121
PO box <3204f Ogs,NMtn. to 5630& 9204 5152444124
i= 515-219w1937
Certified Abstract of Driving Record
Inquiry Date:
10/12/2015
DL/ID #:
433ZZ4432(IA)
Customer #:
3712754
Name:
Hake, ]on Kenneth
Class:
A
ID Status:
None
Address:
145 N DUBUQUE ST
Audit #:
7063375
DL Status:
VAL
Office of Driver Services
Office
Issue Date:
06/22/2013
CDL Status:
VAL
City/State:
NORTH LIBERTY, IA
Expiration Date:
04/07/2018
CDL Cert Status:
Excepted Interstate
523179211
Endorsements:
LNPT
CDL Med Status:
None
Mailing Address:
145 N DUBUQUE ST
Restrictions:
Corrective Lenses,
Restriction
None
No Class A and B
Supplement:
Passenger Vehicle
Date of Birth:
4/7/1959
Mailing
NORTH LIBERTY, IA
Sex:
M
City/State:
523179211
History Information
CLEAR DRIVING RECORD
Name: Hake, Jon Kenneth DL/ID: 433ZZ4432
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office 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 official 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 caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
10/12/2015
..........
Office of Driver Services
Office
Iowa, Department of Transporation
ria
Name: Hake, Jon Kenneth DL/ID: 433ZZ4432 -
ZL"
iv
p
STATE OF IOWA
Criminal His(or), Record Checif 3=
Request Form 0
a� A3
UC:I Account Nlunlec _ t.(,�L--e .__r.
(if applicable)
To: Iowa Divisim1: of Cvinlinal [nveWgatimn Froto: _ City o1 lcwu City
lrupparfOpel-AfiongBurAu,VFlow. CRY cicriFSE7fftce
215 E. 7"' Street 410 E• Washln Ion Slree(
f%Es h$vines': Cmva 50319
555 725- 0 ra-6ity�Y sY2M
(555)725.6,0X(1 lax:
Mimic: 319.356-5041 __
Fax;
I am re ucstin atm) )owa Cfiminal I-lisloy Record Check on: _ __ �Id
l_.BSt Name (Man chlor)) I-'I'S1'St �rRtI1C (mandalory) ndlC h_RLUC (recommended)
HAS
Dat Of Bit'th (mandalory) Gender (mandatory) Social Security A1umber (recommended)
_ L/
Walvet" hilfOrnia(low Without a signed waiver from the sobject of the request, a complete criminal history record may no(
be releasable, per Code of Iowa, Chapter 692.2, For complete criminal history record informatiol), as allowed by law, always
obtain a wah'er signsafure from the sublect of the request,
Wabl?P RefeaSe: I hereby give rcmli"ign for the above rcyussling official to conduct on Iowa crirpinal history record check n'ith the vivision or Criminal
blv¢StigVimr(DCO. Any(riminal hisiolYdala eonenulag me tialismaair"Hi,n/ycd'brebe DQ may be releasedas allmved by lase.
PPO IVEP-Signa itfl'e:_
Iowa Criminal History Record Check Results
As of_ a search of the provided name and dale of birth ieveq)ed: `.
>' .
1\Ip 1U{va L]'1mnlnl l'115t01'y Record fuund with C7C1 x.=;_-,',
Iowa Criminal Record attached, )JCI fl rte, ' LO
.' Jv
))C'I inilialS
DCI -77 (08/23/10)
Received Time Oct, 13, 2015 10:250 No, 0044
A MGQ'ON mai}e21}3anul IYUIU1l10 AIC MOO II S11) 'hl'?c0