HomeMy WebLinkAbout16-004CITY OF IOWA CITY
410 East Washington Street
Iowa City, towa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO,_) (sy -t�L—
(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
1. Name (REQUIRED) [
2. Address (REQUIRED) l l
3. Contact Information (REQUIRED) Email:
Middle
)C 1 LCvnlL0 (';0 50'lteli Phone _3(y"- 3ZS - 1 36-7
communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ y eil D u
5. P\rior experience in transportation of passengers: l ?-VDvJ C �r l t e i�I�LIr� U�✓a C ULnr>A
YlI A A.-. . - O 1
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 7 -ems
Type of offense
Where
When
What happened to the charge? (Circle one)
Convicted Dismisse Deferred Suspended Plead Guilty Other
Have you been arrested /charged wit any traffic offenses in the last five years? _�
Type of offense
What happened to the charge? (Circle one)
Convicted Dismissed
Where
When
Deferred Suspended Plead Guil Other
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 provJde,4he.^n`:
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE,CERTIFD s
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW'-
Ln
EVIEW'"°
Ln
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby .c42 that I have issued to me by the Iowa Departm nt of Transportation a valid Chauffeur's license number
1 xX ) 5 issued on pZ127 j /'expiring on D 20 I understand that if I
falsely answer any questions in this application, that this application may be denied. I agree hat 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 ofApplic Date 12
STATE OF I0WA )
COUNTY OF JOHNSON 1
Subscribed and sworn to before me by i'vtrz,-c ecu R, Y2oti (fL on this % 2 day of
I.L z
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 ) � I' 1�
7
Signri r o olice Chief or designee
/r
ate
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.
SignXure of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
CIerO/ IDRIVHADGEAPPL92014amended.00c 03/2015
tV
s~
- c:n
CIerO/ IDRIVHADGEAPPL92014amended.00c 03/2015
Iowa Department of Transportation
i y. � t3'tl(( II:1rb'..r OrU r s
l'!] r. j"26_1 -1. %I[ a lyttx'ICt4 A 5lc'.' _I..r''! �l1 .!
1. V 51 3 1'.S;
History Information
Convictions
CitationDate
Certified Abstract of Driving Record
ACD
Inquiry Date:
1/12/2016
DL/ID;C:
554XX1775 (IA)
Customer S:
2379862
Name:
Ramirez, Margeaux
Class:
B
ID Status:
None
Speed
Rose
IA
Address-
211S
Audit X-
8880563
DL Status:
VAL
WESTMINSTER ST
Issue Date:
02/27/2015
CDL Status:
VAL
City/State:
IOWA CITY, IA
Expiration Date:
03/11/2020
CDL Cert Status:
Nan -Excepted
522454942
Intrastate
Endorsements:
PS
CDL Ned Status:
None
Mailing Address:
211S
Restrictions:
Corrective Lenses,
Restriction
None
WE'S`TMINSTER ST
COL Intrastate Only
Supplement:
Date of Birth:
3/11/1983
mail -Ing
IOWA CITY, IA
Sex:
F
City/State:
522454942
History Information
Convictions
CitationDate
Conviction Date
ACD
Explanation
CountylUR
IA
10122/2013
11 127/2013
S93
Speed
Johnson
IA
05/2512015
106/1612015
S92
Speed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
JUR
02/08/2008
425311
IA
10/22/2013
764464
IA
Name: Ramirez, Margeaux Rose DL/ID: 554XX1775
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of T-Rinsportation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is:a:'tfee arxLaccurate.,mpy of
an official record currently in the custody of said Office, and that I have been authorized by the DirecCoh•of the4ewa 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 docurnent Ankeny,; Iowa
this date: - Cri
1/12/2016
it : "� •., ±�
D, d. T
Office of Driver Services
Iowa Department of Transporation
Name: Ramirez, Margeaux Rose DL/IO: 554XX1775
on/IJan. 11 20161E11:21ANCae,Div of Criminal Investigation (Fax)31933e27No.5117 P:.k2•ooz
To: Iowa Dlvlalon of Criminal lnvc
Support Operations Bureau, 11
21S E. V4 Street
Des Molner,lnwa $0319
(515) 725.6066
(5111) 725.6080 Fax
I am reouestine an Iowa Criminal
i
STATE OFOWA
/nal History ecord Check
Request li' rm
Floor
I Rnnnr,+ r`ti-qtr
'd r•.,
�•'•�tti�l . 1
DCI Account Number: _967-F
(:fappaahte)
From: Yellow Cab of Iowa CU
PA. Box 428
Iowa City, IA, 6x244
(319) 338-9777
Phono:
rax: (319) 339.7302
Last Name Nondal First NamO mandol0 )''
li'Iiddlo Name recommended)
Date of Birth (mandatory)
Gender mandate
'Social -Security Number rewmmendrd
- 3
❑Male ZFernaic
Waiver li(formaflon, Without a signe waiver from the subject oi
the request, a complete criminal history record may not
be releasable, per Coda orlowa, Chapter 692.2. For 00JUD1.0to erimin
d hletory record Information, as allowed by law, always
obtain a waiver si netura from the suble t or the re uest,
Waiver Release; I hereby glvc pm 6sim Port c above mquetling omelal to m'dL
at as low& otimind h1wry record check w+llithc Dlvlalon otCriminal
Imest+gellon (DCI), Any crlminal hlr:ory dela conteming me that Is maintain bytheDC
I may be released as allowed bylaw,
Waiver Signa
I
`�Yyi1j 1.1lur&tlttl E71I`Jyury i(ecul'o 1,11 UK meSults PCI use only)
As of \ 1 l \r , a seafch of the provided name and date of birth revealed: y
0
No Iowa Criminal His cry Record found with CI
❑ Iowa Criminal History, Record attached, DCI # `
r, j r,
DC initials f'`'
DCI -77 (08/25110)
Received Time Jan. 8. 2016 10:43AM No. 5021
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