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Home My WebLink About15-281� r 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. ./ moi- Q ' 3 1 (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) Email: 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) _ 5. Prior experience in transportation of passengers: - 0 2/625Wai f, Ctir communication sent via email) /2—(8 0 :2 2 - Last Cell Phone: 31 9'3�2J7�.341-Co 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? _ A16 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? yo Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty OtherA J 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /V o 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 thr�.name(s) /)o DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE -CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CsHIEFUVIEI(V .. You must apply for an individual Department of Criminal Investigation Report (form avalloie I on request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTAIRY)L 02/201.5 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 L{ 3 (9 W lar 4 SSR issued on 10-2q- ('f- expiring on �' —{k-22 . 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 �Date �� STATE OF IOWA ) COUNTY OF JOHNSON ) S ybscribe I a d sworn to before me by e a Syn L� S�� on this � J� day of a KELLIE K. TUTTLE the State of Iowa 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 V 21116 6-1--) -2 -Z li Signatur ice 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. Sign of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update Z0 Da e,_,_ C9 ClerW [DRIVBADOE PPL92014amended.DOC 03/2015 NGV, 9. 2015 3:20PM D l v of CYfminaI Inv es 71 gation Ne.0556 P. 1/1 FrOm-ciry of Iowa qtly Clerk CITice 319 36a6d[37 11/06/2016 11:26 Na1s P.00M/002 STATE OF IOWA Criminal History RecoYd Check w Request Form DC1 Amount Number: LA o- -r-� (ifapr ylicnble) To: lova 17iviaiou 01 Crialinal Yhvegigation From: City of Iowa CItE__ __ _ Support Operations tlureau, 1" Floor City Clerk's Office 215 G. 711' Street 4fo lr, D4 sllington Steeet Lees Motiles, Iowa 50319 - (515)725-6066 (515) 725-6080 Fax - �- Phone: 319-356-5041 Fas: 319-356-5497 12111 reouestil1P an Iowa Criminal Hicinvv Ppmetl Chack nn 1!.ast ]Name (nlandalory) First Battle .....a wry) Middle Name- (,,commended) c^1 ROL5rnu5Eio-h Perry llah Date of Birth (mandamly) Gender (mandatory) Social Securi ' Dumber (mommendea Dale ®Female 1{-$5 `i0 Glf-z/ {4"[liver h1f0rmation: WI(Ilou( a signed waiver from thesubleet of the request, a complete criminal history record mAy not be releasable, per Code of Iowa, Chapter 692,2, For complete ct9minal history record information, as allowed by law, always obtain 2waiver 5_ ignaturefront thesubjeetofthe request. -1.traher)Zelean-l-hueby givrpermission-fortltrabove requeAng'affieialim[duct nn lowa'cPi7niriallils ory rT acorn cliec1-iiilh lti�Drvis�ono rrmT�lal -- fwlesli �-utim (M). Any criminal Mildly dela concerning mt that is mail�"��Iaa1mcd by the ))Cl na) be mlehsw as showed by law, lijrylVCY'StyxlRlrGf'C:�1/cdd�t�.�cVid�.,�_-��D.�t� N', As of _1 a search of the provided name and date of birth revealed No Iowa Criminal History Record founts with l)CJ 11 lova Criminal history Record attached, DC1 # DCI ini(ials_ DC.I-77 (08/25110) Received Time Nov. 6, 2015 10:15AM Klo, 1557 o - 11 (3ty o5c Only) c^1 CD Lj r o - Iowa Department of Transportation jl'239 1131 Certified Abstract of Driving Record Inquiry Date: 11/10/2015 DL/ID #: 430WW8558 (IA) Customer #: 1306832 Name: Rasmussen, Perry Class: D ID Status: None Allan Address: City/State: Mailing Address: Mailing City/State: 414 Pleasant St Audit #: 8571396 DL Status: VAL Issue Date: 10/29/2014 CDL Status: None Iowa City, IA 52245 Expiration Date: 12/18/2022 CDL Cert Status: None Endorsements: 3 CDL Med Status: None 414 Pleasant St Restrictions: NONE Restriction None Supplement: Date of Birth: 12/18/1960 Iowa City, IA 52245 Sex: M History Information CLEAR DRIVING RECORD Name: Rasmussen, Perry Allan Ell 430WW8558 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: i IOWA '.. D. Q. IF.. Name: Rasmussen, Perry Allan DL/ID: 430WW8558 11/10/2015 Office of Driver Services - 0: Iowa Department of Transporation M- ey CIO .. rv.�