HomeMy WebLinkAbout15-278rlll���
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED,
IDENTIFICATION NO. _ /5-0 %t'
(Office Use Only)
APPLICATION FOR TAXICAB I 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
3. Contact Information (REQUIRED) Email' L�);12Jt1)1,�t ,;2(i'Lrh Arw Cell Phone: _ I
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) I f )2l 2I P,
b. Taxicab Business Name (REQUIRED)_ I�Lal, lib, e Dry
5. Prior experience in transportation of passengers: 111 t Ll t"c , Via, (-,i,
Q
Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? M) )
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? `l (-5
Type of offense Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred SuspendedPlead GAy Other ,
C( Irv.
8 Has your driver's license or chauffeur's license been suspended or revoked inihe las0ve years?
Type of offense Where yy}1en r
_< xi D
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide thrE.*aaame'�s
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 herebyrcerti that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
a i
issued on &aoi f expiring on I%2� rig 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, C apter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
STATE OF IOWA )
COUNTYOFJOHNSON )
Sub cribed and sworn to before me by `-Mcle ��l �'•- ry�P_ on this � � day of
�>I � ' /
`,`i -i ie K. TUTTLE. _Notary Public in and for the State
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
Signature o"776 Chief or designee
it 1l 2- /27) 5
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.
Signafl re of City Clerk or designee
Office Use Only
Date
tia
c:a
Approved application r""
DCI report;
State certified driving record
Website update
t
rQ
-d- Y
geMIrAXIDRIVBADGEAPPL92074amentledDOC 0312015
17:aIDWAD
Office Of Driver Sery}ses
PO Box 9204 i Des. Moines, to 50.=138-42{14
Phoria 515-244-S-124 i SOU-�i32-8121 i Fax 515-239-1837
www.iovadatvov
Inquiry Date: 11/5/2015
Customer #: 1998958
Name: Kramer, Gale M
Address; 2890 HIGHWAY 1 SW
Certified Abstract of Driving Record
DL/ID #: 556YY2949(IA)
Class: D
Audit #: 7687981
Issue Date: 01/10/2014
Expiration Date: 01/12/2019
City/State: IOWA CITY, IA 522407605 Endorsements; 3
Mailing 2890 HIGHWA`( 1 SW Restrictions: Corrective Lenses
Address: Restriction None
Mailing IOWA CITY, IA 522407605 Supplement:
City/State:
Date of Birth: 1/12/1959
Sex: M
History Information
Convictions
CDL Permit Class:
CDL Permit Issue
Date:
CDL Permit
Expiration Date:
CDL Permit
Endorsements:
CDL Permit
Restrictions:
ID Status:
DL Status:
CDL Status:
CDL Permit Status:
CDL Cert Status:
CDL Med Status:
None
None
None
None
None
None
VAL
None
ELG
None
None
;:itaticin Date conviction Date ACD E: ptanation -. -.-. County JUR
02121/2011 '03/29/2011 - - _592 ',Speed _ _ Johnson dA
Name: Kramer, Gale M DL/ID: 556YY2949
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:
p�p�
_�0®y>EAIBtf
11/s/2015
�tr9
IOWA s
b+r +f
y 1
office of Driver Services
95,
Iowa DepartmentTransportation
Name: Kramer, Gale M DL/ID: 556YY2949
Nov. 6. 2015 9:24AM Div of Criminal Investigation No.0393 P. 1/1
F,__.,-1., 1J1— -. n Cie,. v1—w 19/06/2015 16:51 P$18 P.002/002
STATE OF IOWA
C1>;9liifnil2alisisary Record Check
Request Form "
f)CI Account Number: CCZ_- t
(ifapplicable)
To. Iowa Division of Criminal lovestigatian From: _ Clty oFtov:e City
Support Operations Bureau, I"Floe I, City Cleric's Office
215 L. 7'I' Street QIo E. Washington 3€reef
Iles Moines, Iowa 50339
c
T-.2444---
(515)
2? 16 ---
(515)725-60A0 Fos
— ----
Phone: 319-3s6-5041 _
)tas: 319.356-5497
1 aril rcoucstina an lowa Criminal History Rtcord Checic nn.
Last Name (niandawr.)
]first Name:(mandlwy)
Middle Name (reean,mmlded)
e
(�l
Date of Birth (n,m,dawry)
Gelidetr (�n,a,ldalory)
Social Securitv Number (mconninmdcd)
�( �% � 5�Male
❑lpemale
��j�-��" ��jZ?
grnirer' Infornlretiaw Without a signed waiver from the subjeet of the request, a complete criminal hlstoiy record may no(
he releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain a wayel'signature train (lie subierl of the request.
1'l'aiverReIease..-iI ehy give Ten1ussion for IIIc move requesdngofficiplldcondueliwlDwa iYimnlaIIislory record-chec syiili the Divi<.ionaicnniioel
Inresligation (DC I). Any edminol history data con�111B nog Dy tlm DCI may be released as allowed by le,v.
WaiverSlgnafure:�_~
Iowa. Criminal History Record Check Results
(DCI a5L nilly)
As of // /5J a search of tlic providcd naive and dale of birth revealed::
No Iowa Criminal History Record found with DCI ri'.
d IOP✓R Criminal History Record attached, DCT #
1 c
E.:
DCT initials�
0
DCI -77 (08/25/1D)
Received Time Nov, 5. 2D 15 2:42N No, 1521