HomeMy WebLinkAbout15-227CITY OF IOWA CITY
4 10 Fast Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED) -
2. Address (REQUIRED)
IDENTIFICATION NO. %Z %
(Office Use Unly)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAS 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
3. Contact Information (REQUIRED)
Middle
Phone:e��-G�t�
4a. Chauffeur's License expiration date (REQUIRED) (-)-J r DLA
b. Taxicab Business Name (REQUIRED) S2.Acmuli CaNp
5. Prior experience in transportation of passengers: Au
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
P'
7. Have you been arrested /charged with any traffic offenses in the last five years? � C�
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other f
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ��
Type of offense Where When
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' Tll 1
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE eURF RgYIEW
You must apply for an individual Department of Criminal Investigation Report (form ava upgp req).
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(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARIEw_ Gj
r r-
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
loner g5Iii issued on r � expiring on 3; L} I;)"fi I understand that if I
falsely answer any ques ions 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 1 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 Applicanot� Q_Jcy° Date -1�l
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by K u : e rA ) _ C, n tln / on this C9_-1day of
.�,... nV c UAYFR Notary Public in aR for the State of to
My col
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 d e of Chauff license L I w
Sig ature of Police Chief or designee Dae
21
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA d)TY FOR h
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Signa%ffe of City Clerk or designee Dat
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Office of Driver Services
FO Box 92174 ; Des Moines, tA.503f76- 204
Phrase: 515-244-9124 I BOG -532-4521 I Fax: 515-235-1$37
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Certified Abstract of Driving Record
Inquiry Date:
B/15/2015
DL/ID #:
060CC9569(IA)
Customer#:
4499601
Name:
Carroll, Karen Lynn
Class:
D
ID Status:
EXP
Address;
2429 WHISPERING MEADOW DR
Audit#:
9342492
DL Status:
VAL
Issue Date:
08/15/2015
CDL Status:
None
City/State:
IOWA CITY, IA 522406807
Expiration Date:
03/04/2020
CDL Cert Status:
None
Endorsements:
3
CDL Mad Status:
None
Mailing Address:
2429 WHISPERING MEADOW DR
Restrictions:
NONE
RestritHgn
None
Supplement:
Date of Birth;
3/4/1976
Mailing City/State:
IOWA CITY, IA 522406807
Sen:
F
History Information
CLEAR DRIVING RECORD
Name: Carroll, Karen Lynn DL/ID: 060CC9569
Pursuant to Iowa Code 4321.10, I, Kim Snook, Director of Office of Driver Servlces, Iowa Department of Transportatlon, do hereby certify that I am the custodian of the records held by the Office
of Driver Servlces, that this Is a true and accurate copy of an official record currently in the custody of said offer, and that I have been authorized by the Director of the Iowa Department of
Transportation to sa dertify.
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:
Name: Carroll, Karen Lynn DL/ID: 05OCC9569
V,."
8/15/2015
IOWA
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Phone: 319-350-Sp41
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Reteivad Time Sap,17. 2015 8.56AV No 8192
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