HomeMy WebLinkAbout15-226r t
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1 Name (REQUIRED)
IDENTIFICATION NO. /S-- ✓c
(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
Last
n;,\
2, Address (REQUIRED) -�) J \ 2 ksN e,- �\ v,p1 ��� r1 C S J z )
3 Contact Information (REQUIRED) Email: 6 �qr_ 's �,a V1� C ' , Cell Phone
(All written communication sent via eindil)
v r.
1 ` 1
4a. Chauffeur's License expiration date (REQUIRED) \ L) \ \ $3 \ \ ti
b. Taxicab Business Name (REQUIRED)
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? i C
Tvpe of offense
Where
When
What happened to the charge? (Circle one) eF�,:y
Convicted Dismissed Deferred Suspended Plead Guilty - *r
7. 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
Convicted Dismissed Deferred Suspended Plead Guilty Other
19
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? n , h
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 names)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02!2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that have issued to me by the Iowa Department of Transportation a vali Chauffeur's license number
�{ � + Z�- 5 issued on l S expiring on ( 1 I understand that if I
falsely answer any questions in this application, that this application may be denied. I agree 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 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 g)'�) 'kLfG Date / - I' f
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this \�8}c� day of
and for the State-bf Iowa
d13�n
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).
piration date of Chauff license _
\I "-�\ )
cZ
Sinature of Police Chief or nee
-174016
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.
�CGtG�nJ /� •7�(�/Ly
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Dat
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Sap. 14. 2015 2:08PM Div o1 Criminal Invastlgatioo No, 7866 P. 1/4
GIBlk 09/09/2016 13:17 8261 P.002/OO2
C"'iffihial History Ree(11-d Cilecic
y Reques[ Form
To: Imo Mvisior. of(YiminA Inve%tigaGo❑
-`snphori Opera ions Clureau, I" Flow
215 L:, IIh 31,ut
Du Moines, Iowa 50319
(575)'125-6066
(515)'725.6060 Vax
Record Chcck on;
DO A"oti ( Nunthcv�J IQ y�r
('Ny clerWs OFFICE, - --
410 L NVashin Ion Si e
. Lulea Cky, _522411
Phone, 319-356-5041
Fa s: 31,9-356-5497"`--
- owa Urxlncnal History Record Check Results
As of_y q ���cj a search of (Ile provided name rind date of 6irlh
IR No Ionia Crimina) History Record found with [)('I
❑ lowa C;rinaioa) History Record attached, llCl !f
DCl Initials,
UL:f-71 (p8/25I I U)
Received Time Sep. 9. 2015 1:12PM No. 5216
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