HomeMy WebLinkAbout15-290-ftlwmn-� At
CITY OF IOWA CITY
410 East Washington Street
jowa City. Iowa 52240-1826
(3191 356-50
(319) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. I _�- --��O
(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
2. Address (REQUIRED) �� Inf} 7 roc -K Cf<
3. Contact Information (REQUIRED) Email: wOy ® Q
RE
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) �eLL
5. Prior experience in transportation of passengers:
Cell Phone: 3I � `1j ;�7 Z-3
email)
1�
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
I , 1
Where
or—
What happened to the charge? (Circle one) i ( 1I7
Convicted Dismissed Deferred Suspended Plead G ' y Other 1 ��' t4 d E /y
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
9. Have
you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro?!da' he mrtame(s),, ,,
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C,HIr;K RFMEW i"F'I
You must apply for an individual Department of Criminal Investigation Report (form available ups reque'sf).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/201.5
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certi that I have issued to me b the Iowa De art ent of Transportation a v lid Chauffeur's license number
140 � z � � (a �j y issued on I :,3e
;n 1j expiring on O LOI`a' , I understand that if 1
falsely answer any questions in this application, that this ap lica ion may be denied. agr 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 ree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provi ' Titl 5 Chap er 2 fth ity Code. (Needs to be signed in fir t of a Notary Public)
Signature ofApplic11 ant Date
STATE OF IOWA )
COUNTYOFJOHNSON )
5b scribed an I sworn to before me by />/ LK ��fn Gi ZY on this + day of
/c�!S
KELLIE K. TUTTLE r1 It, /-C— 1_
coa,: `7-I..., ^.lumbar 2216dfl ary Public in and for the
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 �" iowa City�(ohM 9, Chapter 2, City Code),
d e� of C �uffeu ' license I � I r� 10 u
of lice CYfi r signee 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.
2",�) - %
Signalme-of City Clerk or designeeC
1-4-
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Office Use Only
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Approved
Approved application
DCI report
State certified driving record
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FYeNov18. 2015,,, P,: 47AMhIer,Div of Criminal Investigation 11117/2o15 1 2,No. 222%; c,P, 1/1003
SATE OF IQDW
CIriminAl History Record Check
Requer t Form
To: Iowa Division of Criminal Grve2tigatlon
Support operatlons Bureau, I" Floor
215 & 7"' Street
Des Moines, Iowa 50319
(515) 725-6066
(51.5) 725-6020 Far;
DCI Accounf Number: �y'f U O0d —t
(i(appliwble)
From: CRY of Iowa City
City Cleric's Office
410 E. Washington Street
Iowa City, 1A 52240
Phone: 319-356.5041
Fax: 319-356-5497
1 am req!!esting au Iowa aIrrIinal Histol Record Check ou;
Last Name (mandatory) Virst Name (oanamery) dfd111,1me (reconuuendcd)
s E
Date UI ]>l1'fh (maadamry) Cr etlder mandatory) it)t Number recommended)
il'Iale ❑.female
1'haive• Inf0rniai /t; Without a signed w ver from the subject of the request, a Complete Criminal history record may no(
be releasable, per Code of Iowa, Chap(cr 692.2. For cor, plete criminal history record Information, as allowed by law, always
ehlain n waivor rieno Mrn Vv— #hn o.. r.l e,.r .. ,kr--�..-...
Waiver Release: ll)crcby give permission fortbe above rep 5 ngaffieiuI le ndvcta orva crbuinal hi story record clleck.vith the Division of Criminal
n,vcsligatim, (DCI). Any criminal history dale eoncran ng n thatn�aimaine� b}UC ray be released as alloncU by lea.
Maim.
l
lo`<ra Cr1121irlal Histol• , Record Check ltesalts
As of a search of the provided name and date of birth revealed;
rz
= ...
_3
F
s
Fri
No ToU>a Criutir7srl Iiistory Record found with L)CI
❑
Iow,a Criminal History Record attached, DC,14
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DC1 initials
call
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Perelved Time Nov.17. 2016 4:16PV No. 1288
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Inquiry Date: 11/24/2015
Customer #: 3636560
Name: Vornbrock, Rick Page
Address: 150 PADDOCK CIR
Office of Driver Services
PO box 42041 Des Watf[es• R.$ 503j6-92&4
Phone: 51,5-244-9114 Fax: 5 F5-239-1 S37
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Certified Abstract of Driving Record
Dil #:
803ZZ2363 (IA)
Class:
D
Audit #:
6633584
Issue Date: 01/22/2013
Expiration Date: 01/09/2018
City/State:
IOWA CITY, IA 522407201
Endorsements: 3
Mailing
150 PADDOCK CIR
Restrictions: Corrective Lenses
Address:
08/21/2013
Restriction None
Mailing
IOWA CIN, IA 522407201
Supplement:
City/State:
None
DL Status:
Date of Birth:
1/9/1951
None
Sex:
M
—"
c„ r
History Information
Convictions
COL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
L''a,II$aTr='.tion
CDL Permit
None
Endorsements:
08/21/2013
CDL Permit
None
Restrictions:
IA
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
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P.Utl2VPS:$3J:I )ai.e
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L''a,II$aTr='.tion
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.Ats 32
08/18/2013
08/21/2013
N63
Driving Wrong Way on One Way Street
Johnson
IA
02/18/2015
.02/27/2015
S92
Speed
Johnson
IA
Name: Vornbrock, Rick Page DL/ID: 803ZZ2363
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, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date:
11,
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11/24/2015
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Office of Driver Services
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Iowa Department of Transportation ....-.
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Name: Vornbrock, Rick Page Dll 803ZZ2363
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