HomeMy WebLinkAbout15-276CITY OF IOWA CITY
410 East Washinglon Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO
IS a-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
3 Contact Information (REQUIRED)
R
4a. Chauffeur's License expiration date (REQUIRED) _
b. Taxicab Business Name (REQUIRED) _ Y k�i-LGW
5 Prior experience in transportation of passengers:
l
U,e'--
email)
Phone- ` 8e`
y£a4S
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A -U
Type of offense
A -
What happened to the charge? (Circle one) 04—
Where
Convicted Dismissed Deferred
When
Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
1.1
Type of offense
Where
Law 9` Al v3c--Tw�
What happened to the charge? (Circle one)
CoC rivl�ctedd Dismissed Deferred Suspended Plead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
9 Have you ever applied to be an
Where
When
J0
City taxi driver using a different name? If yes, please provide the name(s) NO
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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportationa v lid Chauffeur's license number
�q'-j 3 s z issued on rr Gz zP 3 expiring on l o�o2cr b . 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 toallow agents or p oyees o he City of Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to thi appli rtion, d I furth r agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the prov' ions Title , Chap r 2, of the de. (Needs to be signed in front of a Notary Public)
Signature of Applicant . Date -L4
0 2C' 5—
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me b �\ q�,,,,'
Y � A �\ a�.-e on this � � day of
the State of
3(1
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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur' license l U I l I I qI, 0 U
Jaz l( fo �0t
Signature of Police Chief or 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.
Signaftrre of City Clerk or designee
Date
*kkk***xh***xxxx£****#*#******xwww**********xh**************k***xxxxxxx*w**#********xxxxxxXx*xm********£xx*xx*xww*k********k**Xxxxx**xx***xxxxxx
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CerwrwnDRivaADGEAPPr92014amended.Doc 0312015
Nov. 4. 2615 10:16AM Dlv of Criminal Investigation
11/02/2015 17;26Y5110lt Cab of Iowa City
No. 0180 P. 1
(FAX)3193382708 P.002/002
1
STATE OF IOWA
1y �7.ie yyea 'Criminal History 1 • Checkr ��14�d.•en G
rN(�. �lQl!.N',I�!' � �'S_u�; r^ten•" _
DCI A000unt Number: _9967-F
(If oppllcnble)
To: Iowa Dlvlston of Crlminal Investigation From: Yellow Cab of Iowa City
Support Operations Bureau, I" Floor P.O. Box 428
Z15 M 7" Street
Des h?o;nos, Iowa 501319 Iowa City, IA. 52244
(515) 725-6066
Phone:
Fox, (319) 939-7302
I am raeuestinn An Iowa Criminal hl(stnry Reenrd Cheele On-
Last
m
Last Name inioderd)
First Name (mandua '
Middle Name recommended)
7� �-LEN
Date ofrBirthmond oryy))
Gender mondliia
-Social•Securl Number recommended)
/
11 7 1
p4nle ❑Femaie
0/0
Walver Information: Without a signed wnlver from the suhlact of the request, a compl@te �rlminal history record may not
be releasable, par Code of Iowa, Chapter 692.2, For complete crlmipel hlstory-r000rO Informatlon, a9 allowed by iew, always
obtalh a wAlver sl nature from the sub act of the re u
W01ver Relaase, I hcrcby aloe perml6sloo(rilice$ araqQIngoM91tw. coneual en Iowa criminal history record check with rhe olvision ofCrlminel
Invmngenen (OCs. My criminal hluory data w a Ihel the DCI n roloased ec ellowc4 by law.
Wai ver sign arurel --
Iowa Criminal fifstory )?,ecolyd Check Results (DCI oac only)
A5 of �� �, a search of the provided name and data of birth revealed:
ESI No Iowa Criminal History Record found With DCl
❑ Iowa Crirninal HIStory Record attached, DCI #
DCI initials,,
DCb77 (08/25/10)
D...:.,,1 7:_.. AI,. ,. 1 M11f F. 79 Dtf. MI 1100
I
tri
/' Iowa Department of Transportation
0mce fit urrver services i Toll F reel rf0(t 632 1121
PO tMX 9204, CIES MOIRES, [4 50306 9294 51S 1Ac15124
iF,kh 515,239 183r
Convictions
Citation Date
Conviction Date
Certified Abstract of Driving Record
Ex lanation
Inquiry Date:
11/2/2015
DL/ID #:
749AJ3552(IA)
Customer #:
6159996
Name:
Blake, James Allen Class:
D
ID Status:
None
Address:
42 W COURT ST
APT Audit #:
7493552
DL Status:
VAL
403
Issue Date:
11/02/2013
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
10/11/2018
CDL Cert Status:
None
522403836
Endorsements:
2
CDL Med Status:
None
Mailing Address:
42 W COURT ST
APT Restrictions:
NONE
Restriction
None
403
Supplement:
Date of Birth:
10/11/1961
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522403836
History Information
Convictions
Citation Date
Conviction Date
ACD
Ex lanation
County
JUR
09/29/2014
10/22/2014
592
Seed
Johnson
IA
Name: Blake, James Allen DL/ID: 749A73552
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:
11/2/2015
" IOWA117
s�€
D. 0. T...:
ky,�z Office of Driver Services
Iowa Department of Transporation
Name: Blake, lames Allen DL/ID: 749A]3552