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HomeMy WebLinkAbout15-268IDENTIFICATION NO. % -07 (9B l z (Office Use Only) APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) I�}.S(_n( ffi>1MA) kr)dyit Lez 2. Address (REQUIRED) Wo lgrf v ST. D). 3. Contact Information (REQUIRED) Email: tw+, Cell Phone: 119 -qoo -6�tl ? ? (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) lel lov✓ to 5, Prior experience in transportation of passengers: n Ong 6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere? V10 Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? i1Q Type of offense 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? nO 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 STATEIERTIQD DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE OHIq REVIEW ry You must apply for an individual Department of Criminal Investigation Report (form avallat�je upon regAe�st). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY '�'' 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I herebpy certify that I have issued to me by the Iowa Dep rtm nt of Transportation valid Chauffeur's license number (1g2.7:Z 2 l issued on Mexpiring on 4110 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 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Q 1'bDate STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by r --.)Sr r, {F . 7-0co I-oi , ey-. on this a� 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 license 14 ✓"/ 2,,� Signature of Policehi f o -designee Date 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. mw Signattfe of City Clerk or designee 10%",3 / 5 D91e Website update ClerkrrAXIDRNSADGE PPL92014ame,dedDOC 03/2015 r -i u Office Use Only C") m rQ f Approved application � DCI report " State certified driving record r Website update ClerkrrAXIDRNSADGE PPL92014ame,dedDOC 03/2015 Iowa Department of Transportation cyhce of Urraef Services 1 loll free) bW 532 1 T21 PO Sox 9204, Des Woes, A 543135 BZ014 515 244 4T24 fAX i;152391'83r Certified Abstract of Driving Record Inquiry Date: 10/21/2015 DEAD #: Name: Rodriguez, Oscar Class: 8530569 Antonio VAL Address: 2120 10TH STREET Audit #: 09/30/2017 PL None 3 CDL Med Status: Issue Date: City/State: CORALVILLE, IA Expiration Date: 522411331 9/30/1989 Endorsements: Mailing Address: 2120 10TH STREET Restrictions: PL Date of Birth: Mailing CORALVILLE, IA Sex: City/State: 522411331 892ZZ9251 (IA) Customer #: 5122888 D ID Status: EXP 8530569 DL Status: VAL 10/14/2014 CDL Status: None 09/30/2017 CDL Cert Status: None 3 CDL Med Status: None Corrective Lenses Restriction None Supplement: 9/30/1989 M History Information CLEAR DRIVING RECORD Name: Rodriguez, Oscar Antonio DL/ID: 892ZZ9251 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: 10/21/2015 . 0- �L fr r} l WA D. - ]. T » �r 44 s 14 941`111111. Office of Driver Services M Iowa Department of Tmnspomtion Name; Rodriguez, Oscar Antonio DL/ID: 892ZZ9251 n� a^ 10,OCt_26. 20151 9_25AMCab Div of Criminal Investigation (FA%)3193382;N0. 9317 P• J01l002 STATE OF IOWAHistorya s1 Tot Iowa Division of Criminal Joyesllgatlen Support Operatlons Bureau, 1" Floor 21$ L. 7'a Steatt Des Molncs, Iowa 50319 (515) 725.6066 (515)775-6080 Fax I aM rOCUOstina nn Tn WA Crlmlhwl Filntns D... A rpt.- b DCI Account Number: _9967-F (Ifoppileahie) From:. 'Yellow Cab of Iowa Ctv F-0. —Box128 Iowa City, IA. 52244 (319) 338.9777 ?lion@; Fax: , (319) 339-7302 Last Name (mandatary) Srlrst Natna (mindslorA Middle Name reeommendoci At4okio Date of Birthl mpa{ndate Gende//rmendaw 'So�cJiall•-SSecurI Number (recommended J��I� ` lldMalo ©Famalo I 29-0�69v Waiver Injormollonr Without a signed waiver from the subject of the request, a complain Qrlminal history record may not be releasable, per Code of lows, Chapter 692.1. For complete erlminal hlstory•record Information, as allowed by Jaw, always obtain a waiver Signature from the tub eat of the reguest, Waiver Release; (herebyove permission for rhe above requerllog olnclel io conduct en Iowa oilmlaol hbioryt000rd check with the Division ofcrlminal Invoilgatlon (DCq., Any criminal hhtory data coneemind me that is maintained by the DCI May bs released u ailawed bylaw. Waiver Signature: 1 r Iowa Criminal History Record Cheep: Results As of (h •7_la-1S , a soaroh of the provided name and date of birth No Iowa Criminal History Record found with DCI Iowa Criminal Hilttory Record attached, DCI #• DCI initials- DCI -77 (06/25/10) Received Time 00.21. 2015 2:27PM No.9067 (001 urs only) 6&A _. uL.0 T'