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HomeMy WebLinkAbout15-254,l P 1 WIMM GTY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. 15 -A 5't (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) 1. Name (REQUIRED) Jo= 2. Address (REQUIRED) Q X1.7 S Middle D �v.�. 3. Contact Information (REQUIRED) Email: .�o� n I �� �' y p t h e a �a6U s 'Aell Phone: 3l -5 i y-171 j (AII written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers. 2 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? e F� Type o_ f offense Where Li Mi,. I Jr�sF_,, _ _ When I What happened to the charge? (Circle one) Convicted Dismissed Deferred SuspendedPlead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? �y Type o_ f� o 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?� o Type o_ f offense Where ter, Then o 9. Have you ever applied to be an Iowa City taxi driver using a different name? } R o If yes, lease r p p p�fideithezgame(s, DEPARTMENT OF INAL DRIVING RECORD MUSTACCOMPANY THISON APPLICATION ON FOR POLICE CHIEF u ---�� REPORT RTIFIED You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereyb certify that I have issued to me by the Iowa Department of Transportation a Vali Chauffeur's license number 3 1 �I lk�� 1 8S issued on to 7 d3 expiring on tl (, s 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) f Signature of Applicant lt I __USI` r— Date [ n �� ! A .k �' STATE OF IOWA ) COUNTY OF JOHNSON _� Su sdr be a xi sworn to before me by e1 o k'� CL C—kS0') on this 'I T ` day of 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 license2- Signatureoff o hief or designee /a� s 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. Signature -of City Clerk ordesigne'e /d :/ / Date cledJrPXI ORIVBADGE FL92a14z ,de .Doc 03/2015 Office Use Only '3 Approved application DCI report W State certified driving record Website update ` - cledJrPXI ORIVBADGE FL92a14z ,de .Doc 03/2015 Oct. 1 2• FSI, pi 1y v 2015 11:4242 Div of Criminal Investigation No. 8332 P. 1/2 of low& cdly Clbrk Office 316 asSSA87 10/0®/2015 13:02 02ea p.002/002 STATE OF IOWA Criminal kitistory Recolyd Check Request Forlm DCl Account Nomber; `[ ) 0 '�- - V_~ (Ifapplicable) w ro: Iowa Division of Criminal luvestigatlou from; _ City of low,© sopPort OPe ALA's Buren u, ln' Floor City Clerk's Office 215 E. 'Ta Street410.C, sAlasllington street Iles Moines, lowa 503),9 (515) 725-6066 lova t,ity 1A =2946 — - (51.5) 725.600 Pax -- — — 111 mm 319-356.504( Fax: 319-356.5497 I am requesting an Iowa Criminal Idistoly Record Check on: Last Name(mandalor) Firsf Name (mandalo ) NYiddle Name (acomrmided) 1 Date of Birth (n idaery) Gender (nlanda m) Social Securi `i uM' LIU' (fecommcndcd) �i0 Male ❑Remale �j O 5 S z. ] Waiver Infornia' 6071: Without a signed waiver from thesublect ofthe request, s complete crhninal history record may vol be releasable, per Code of Iowa, Chapter 692.2, For complete urlminal ltistor} record iuformotlan, as allowed by tea, aIH'ays obtain 9 waiver signature from the sub'eel of the re uest- 1'i!(111re y Peiense: I bcrcby give permission N the aboVc VcpUesling Oaobl to conduc.l an lown crimnlal Iiiuory rcord ch: ck ref Ih dte NVislon of oriminal invcsligadon (DCI). Any criminal history dela conumiug me Thal s mainlaumd y the DClmaybe mkased as alloned by brv, %I iriver Signature: 16611 Iowa Criminal Histon, Record Check Results As of /Q/Z 05-1 a search of the provided naive and date of birth revealed: No Iowa Criminal History Record found with DCI Iowa Criminal Hisinry Recoid attached, DCI # LDgrl i J i DCI initials DCI -77 (08/25/10) Tl,,,a 0,1 0 9016 19•F7PM NL. 0466 Uci.l 1. /U 17 II:4jAM U 1 v 0T 6 r i m i n a I InvestIgatIon CCH RECORD www 01 ARRESTED 19830930 AGENCY; IA0520000 JOHNSON CO SO CHARGE NO— 01 IA STATUTE IA716-6 CRIMINAL TRESPASS TRK#; L24762901 COURT DISPOSITION AGENCXc IA052015J JOHNSON CO DIST COURT COUNT NO— Ul IA STATUTE: IA716-7 CRII7 TRESP TRK#: L24762901 SENTENCE DISP EFF DAT FINE $55 19030930 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE An SENC'E OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SIitcT Of' YOUR INQUIRY, DIVISION OF CRIMINAL INVESTIGATION kc, 8332 P, 2/2 IOWA CRIMINAL HISTORY DCI 00309940 PACE 1 OF I DATE PRINTED— 2015/10/12 DCI !00209946 NAME; TACKSON,aOBN LANGLEY DOR 5E% R,AC HGT AIGT EYE HAIR SRN POB 19600921 M W 600 165 BRO BRO FAR IA CCH RECORD www 01 ARRESTED 19830930 AGENCY; IA0520000 JOHNSON CO SO CHARGE NO— 01 IA STATUTE IA716-6 CRIMINAL TRESPASS TRK#; L24762901 COURT DISPOSITION AGENCXc IA052015J JOHNSON CO DIST COURT COUNT NO— Ul IA STATUTE: IA716-7 CRII7 TRESP TRK#: L24762901 SENTENCE DISP EFF DAT FINE $55 19030930 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE An SENC'E OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SIitcT Of' YOUR INQUIRY, DIVISION OF CRIMINAL INVESTIGATION kc, 8332 P, 2/2 ;ii i U WA DOT wwwimAjadotgov SY, ARi"�n 1 SIWLCR 1 CUSTtlMEF F..' B Office of Driver Services PO Box 4,104.1 Des f0;a'nes, 113 5030E-�203 Phone.- 595-244-°124 i 8D0 -E32-1121 I Fax: 615-23J-1837 wwwJowado gGo Certified Abstract of Driving Record Name: Jackson, John Langley DL/ID: 374AE6185 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, > ;;:...:.%% q� VE, 10/9/2015 DL/ID #: 374AE6185 (IA) CDL Permit Class: None Inquiry Date: 10/9/2015 Iowa Department of Transportation CDL Permit Issue None Customer #: 5530608 Class: D Date: Name: Jackson, John Langley Audit #: 9481266 CDL Permit Expiration Date: None Address: 2975 SUCH MAYER BIND NE Issue Date: 10/07/2015 Permit Endorsements: None Expiration Date: 09/21/2022 CDL Permit None Restrictions: City/State: IOWA CIN, IA 522407753 Endorsements: 3L ID Status: None Mailing 297513UCHMAYER BND NE Restrictions: Corrective Lenses DL Status: VAL Address: Restriction None CDL Status: None Supplement: CDL Permit Status: ELG Mailing IOWA CIN, IA 522407753 City/State: CDL Cert Status: None Date of Birth: 9/21/1960 CDL Med Status: None Sex: M History Information indicated does NOT mean the individual was at fault or given a citation. Accidents - Accident involvement Ca'e Murobrs' Accident Date ]A 112/30/2013 777861 Name: Jackson, John Langley DL/ID: 374AE6185 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, > ;;:...:.%% q� VE, 10/9/2015 IOWA ' D. 0. T.:°°M E g ®f'Ally Office of Driver Services Iowa Department of Transportation Name: Jackson, John Langley DL/ID: 374AE6185