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HomeMy WebLinkAbout15-307�III� CITY OF IOWA CITY 410 East Washington Street Iowa CII Iowa 52240-1826 19) =:!7—FAX 5E 5t1'fiU (319 355=5 :7 F X Authorization Number lk5--Ps— 5 VJ (Office Use Only) APPLICATION FOR TAXI I MOTORIZED PEDICAB VEHICLE DRIVER (Pollee Department review must be made between 8 a.m, to 3 p.m., Monday — Friday.) Failure to complete the "reaafred" information will result In denial of the aoalicafion 1. Name (REQUIRED) 2. Mailing Address (REQUIRED) _ 3. Contact Information (REQUIRED) Email: 4. Prior experience In transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When 6. Have you n convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense rt-; 7. Have you been convicted of any traffic offenses in the last five years? When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? yk Type of offense Where 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the • c7 , DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIF. DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must appy for an Individual Department of Criminal Inveatigatlon Report (form available upon request). (OVER FOR REQUIRED SIGNATURE AND NOTARY) 09!2014 7 hrtmmaxe igs� to me by the Iowa Department of Transportation a valid Cnauneurs license number `� [' 4 . I understand that if I falsely answer any questions in this application, that this application may bef denied. I ulliderstand that if I falsely answer any of the questions In this application, that this application will 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 a license 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) JI I Signature of Applicants A /I'( V, `� v ` StA Date©�S YOU ARE NOT VALID TO DRIVE ATARI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERICS OFFICE. Authorized taxi driver names are placed on the city website at Icgov.org. xxxaxRxxxxRwxeiN.xxxaararxw.ewxwwwxxxweaewx�:Rzxw<r+w+rwR.ua*wxwwwxxxxxxxxxasr3w:x++x+++xa+w++Mwwwxxs++asawwwar+xw++Kx++++x++.wwxx+w+wx*+exwR�+ STATE OF IOWA ) COUNTYOFJOHNSON ) f/) -S bseribed and sworn to before me by �I`2JLt.--- Ad On this L day of .. tS r j2;A F1 328r4 ¢iuotary Public in and for the State of Iowa ` Nry C9rrirclap F�re� I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that there Is no information which would Indicate that the issuance would be detrimental to the safety, health or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code). llz�ll5 Signet of P ' e Chief or designee Date YOU A OT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. Si atu City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5 W" (height) and prominently displayed to all passengers. tiRRtkiiM'lJfliwlwRR4ilktMt:lllkMltfMilkiMhMMHMR1kk/NMwY141MMitFlRtltRexlrtixYRiRIfIMfYRlYFwwYMf i4YtY:MMY1MiwRFR1eARRhfWWMwRiM'HwRRRiYIYi Office Use Only Approved application DCI report State certified driving record Website update M.VrAX1)MVMDWAVLM4w Doc 09/2014 tan, 9. 2015.10:24AM Div of Criminal Investigation No. 7666 P. 1/7 2015 11:5/AM City Clerk - City of Iowa City Ko. 5524 N. 2 LW STATE I OF IOWA \ q ? Jar rhi fi t:iMiii21l[i ory Recoird Check Request.Form Tot Iowa UtvldonofOrlininallrtvartlgation Support Operatlans $ureau, 3" I+ieor 216 R. 7v' Street DuMohtetslowa so319 (418) 725.6066 (615)725.6010 Fax Iam reaumlina inlowa,CrIminal liisturvRecord Check on; DC1AcmuntNumborr. LIDO (Iteppltre la From citvofiowaClty MyclerRya 0111166 410 2. Woshington SWAst Iowa City, iA 62t411C A Phone- 319-3564041 c— Ax: 310-3964457 Laet N'amo obatimeo Mrst Name (raan&wy) I Middle Name (eecamma,d A- Wsw lova o e, Date of7Birtp (m.rdamm Social Security Number caonlmondsd 5dhlale OPemate U j� (lj Waiver 10forrtt91101e; Without it signed waiver from the subject of the ragaut a complete criminal liloory record may not he releasable, per Cade a fXowa, Chapter 15M.Porcomplate criminal history record information, as allowed bylaw, always obtain a walver*fgmturafroyntheoob eetofthore uesf. Waiver Rdiease:-hereby givaperrolralon far Iha rboyougd f1quM&1fewndudas laws orianpdhtetoye ed checkwith thoniesion OMIMInal lnvmtigonOn (DCI). anyulm9rel hlnoNdue wacsmingmothatpmrlaladl¢dbyrao AClmey beretaea:duanowcd bylety. WaivefMgnatYtrel -QQ �-- , K 1/1 JQy a Criminal History fir¢ Check Results As of � -1 i a search of tha provided namo and data of birth revcalcd; Uf- No Iowa Criminal History Record found with DCI El Iowa Ciriminal HistoryR.ecord attaohed, DCI # IDCiinidals�w Received Time—Jan. 8.-2015-11:55AW4o, 7587` (DClurgonty} .;t t,� ��1 DOT uwm iowadot.goy SMARTER I SIMPLER 1 CUSTOMER Office ufUrWer g'ervices PC Box 92041 Opus Woos, IA 50306-9204 Phona, 535-244-9124 i SPO -532-1121 Fax 545-239-1837 .. "www.WwBdotxJov Certified Abstract of Driving Record Inquiry Date: 178/2035 DL/ID #; 769YYU847 (IA) Customer #: 4292418 Name: AlAsen, Kevan Michael class: D ID Status: None Addrew: 521 1/2 BROWN Audit #; 8730680 OL Status: VAL Issue Date: 12)31/2014 CDL Status: None Clty/State: IOWA CITY, IA 52245 Expiration 11/29/2022 CDL Cert None Date: Status: Endorsements: 3 COL Med None Status: Mailing Address: 6211/2 BROWN Restrictions: NONE Restriction None Date of Birth: 11/29/196£ Supplement: Mailing City/Stats; IOWA CITY, IA 52245 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County Jult 01/16/2012 02/06/2012 )improper Registration [Johnson '.IA Name: Allfson, Kevan Michael DL/lDi 769YY0847 Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Servces, 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 offlclal 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. i 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: Name: Allison, Kevan Michael DL/ID: 769YY0847 1/8/2015 c Office of Driver Services Iowa Department of Trans portatlon