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Home My WebLink About15-305�IIIMIp �� CITY OF IOWA CITY 410 Last Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. (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: O 111P q MA,; /. ((MiCell Phone: (All writtgn communication s6fit via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) A a 3 5. Prior experience in transportation of passengers: 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? tilU 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? �% Q Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ,UU Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prQyide theuF}ame(s) /Jo =_ a t DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE6-, j Tlkl D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE (:RF REVIEW • 'rr1 —a Z Y You must apply for an individual Department of Criminal Investigation Report (form available -upon requ'i�t). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARYr o 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I h�ye issued to me by the Iowa D partment of Transportation a valid Chauffeur's license number 4J issued on -/(ate/ �l expiring on 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, o�the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant i d i� Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Kc,_icd _. -A . B, r1 v._fl on this a C7 day of O ec° eLL,_ P_f- ��t5- 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 offCChaauffeur's license IZD2 tJ_Jl12-So t5_ Signat re of PolicerChief 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. Sigof City Clerk or designee Date Office Use Only Approved application =_ rn DCI report �. State certified driving record ` CD Website update —; CD ClerkrrAXIORIVBMGEAPPL92014.m.nded.000 03/2015 cviwi I. cunni v 1 v vi %�rlinl11al I nl v e s l l g d 11011 N0. 3649 P. 2�3 CI BI .. -, .. ,--- r4 ..., ., rv�e. -12/17/2016 15:9[5 ea -S P.002/002 STATE OF IOWA Cr'lllillal Histolry Record Check a k Request Form 'fo: Iowa Division Of Crinuusl 13wesligatioll Support operations Bureau, is' Flom. 21.5 F, 7" Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax ate of Birth (maddau W-7- t j ml: Ma- r ❑Male '— 7 VC) Account 1\1umbcr; ( 1 (if ^PPlialble) From; Cit ofiowxCdty. City Clerk's Office -- 4101;. Wasbin tUn street lows Clty, lA 52240 pllbim 319-356-5041 Fax: 319-356-5497 `— 0'0 rrnsvertn,/ornlaflon: Without a signed waiver Aram the subject Of the request, a complete criminal history record may nal be releasable, per Code of lows, Chapter 692.2. For complete criminal history record Inrormatlon, as allowed by law, always Obtain a waiver signature from the subject of the request. mai Ver lielea"; 'hereby give Permission for the above repesling official to L V"ft1llen (DCI), Any criminal history data eenceroing me Boot is main(aiaed by l Waiver signature: an Iowa criminal history «cord check lvilh the Division of Criminal be rdea+cd as allmved by[,, lows Criminal Histor Record Check Results As of / l� 15 ,1 search of the p),ovided name and date of birth rcvealed No Iowa Crilnina) flistofy Record found with DCJ ❑ Iowa Criminal History Record attached, DCJ DCJ initials. DCI -77 (08125)10) — --- ~ Received Time Dec, 17, 2015 2:35PM No, 4125 fTl (DCI use only) ca rul {' W C i' C-.1dil J1U"v4A00T <1VA6 f1EIA i p.i �VYY a'Y,i LIYV 4J iJ Lr 4d'k3 T' ...lyi I4TEI� I _ sP1cl��. I (�,1 JrT�z j�..R �{�kd >v, Inquiry Date: 12/29/2015 Customer #: 4718071 Name: Hulme, Mary Annis Address: 3013 STANFORD AVE Office of Driver Services PO Bc* QC4 I Des ti A 57366-9264 Phone: 51:-244-9424 I80Q-532-1321 l Fs7;1,15-339x837 www d'fl8dct.{lav Certified Abstract of Driving Record DL/ID #: 428XX5051 (IA) Class: D Audit #: 9426861 Issue Date: 09/16/2015 Expiration Date: 10/07/2023 City/State: IOWA CITY, IA 522454929 Endorsements: 3 Mailing 3013 STANFORD AVE Restrictions: NONE Address: 06/21/2012 Restriction None Mailing IOWA CITY, IA 522454929 Supplement: City/State: None DL Status: Date of Birth: 10/7/1960 None Sex: F History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: ENi iana2irsn CDL Permit None Endorsements: 06/21/2012 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 Citation Date Conviction Date ACD ENi iana2irsn County IUk" 05/26/2012 06/21/2012 M14 Fail to Obey Traffic Sign/Signal Johnson IA 02/07/2013 04/08/2013 S92 'Speed lohnson IA Name: Hulme, Mary Annis DL/ID: 428XX5051 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: 12/29/2015 IOWA /Q.. */ o rOffic cs of l[meMver eof lTransportatio> IowaeDeparrL`"n --. c.3 CD Name: Hulme, Mary Annis DL/ID: 428XX5051 _ -a rJ