HomeMy WebLinkAbout16-014CITY OF IOWA CITY
410 Cast Washington Street
Iowa City, Iowa 52240-1826
F3 19) 356-5040
(3191356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO.
(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
3. Contact Information (REQUIRED) Email.
lo
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ 4-I r
5. Prior experience in transportation of passengers: _
oma n 19a+ M d i I &)h Cell Phone:
(n communication sent via email)
`6 %(4 S
b i)vwi -
fj fl ZcUI
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? -Kt/
Type of offense Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
I -M&6 ,
Q
Where
ott Ith
When
Other
When
33/0 ld /
/ ?/2u,
What happened to the Kharge? (Circle one)
Convicted e 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? VI U
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prow kfhe
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIL®
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
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 he{ey certify th I have issued to me by the Iowa D partment of Transportatipn a valid Chauffeur's license number
$ C C y N S issued on �!/yth on expiring on W11,112,"12 1 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 prov' ns of Title 5 of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant �� Date ULL/20/S
STATE OF IOWA )
COUNTY OF JOHNSON
Subscribed and sworn to before me by Mca__C�__ A- L, " nn thrq ) 1 ate„ _f
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 Z d l
1
Signatlr o o i e Chi f or designee - n t Date6
-
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.
SignMure of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
/�---
Date
CIBIdTA%IDRNaADGEAPPL92014zM,nded,DOC 03/2015
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CIBIdTA%IDRNaADGEAPPL92014zM,nded,DOC 03/2015
Jan.IJ, 1U 16 1 3JM Uiv of Criminal Investiga{'ion No. 5305 F. 3/3
Fra m:Clty of IOwa Cloy cl"k nfflcc 319 3666487 01/12/2016 16:61 0370 P.002J002
- FAX
S'��A'b'1_�,' Off' IOWA ov"'et
CriminalHistorRequest Form
'Co: Iowa Divlsioa of Criminal Investigation
support Operations Burean, l" Fieor
215 r. 711, street
Des Whits, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax
Iowa G imi
L. a d
G/VM7
1Vanle 01-148,1100
'—Mav l�'
er
f)Cr Account Numbers - F
Y (itnpple bee)
Frog; Cit of Iowa Cit
City Clerk's Or�ce
410 �, WaShin twa Street
fowa�•, ]A 52240
P1101 : 339-356-3041
Fax: 3i9-356-5497
Male ®]female 116
IM
fP2,17
11'Rii'G'Y lrt/OYbiRllort; without asigned waiver from the subject of the request, a complete criminal history Petard may not
be releasable, per Code of Iowa, Chapter 692.2. Far coniplCtc,, criminal history record information, a5 allowed b
obtain alvaiversi naturcfrotnthesubitetofthee. rPet ylaw, always
liueT R : I hereby give permiss ion
hvesdgntion (pcj). for the above requesting official re conducen Iowa ciminal 1,410 y record check with ne Division orCrinlinalycrmaistory
Bala eonurning nm shat is c,ne y the DCl may bt r�,d awed fir;---5-�
WaiverSiannlurfr
As of
A—\a search of the provided name and date of birth revealed:
1\10 Iowa Cfimina) 14i.5tory Record fouled vaidt DCI
® Iowa Critninal History Record attached, DCI
DC] iiritials� >-Lo
nC-77 (08!25/10) y—
Rarcivpd Tim/ .Ian 19 7016 1•G9PN Mn Fidl
lDe7 ase only)
CIowa Department of Transportation
00ce ot 0 wer ;Drvac (TOP Ffee) iM S32-1121
PO Box Q04, Dcs Mans, IA 503% 9X,34 515-244.912
AO FAX 515 2.39.1831
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
1/11/2016
DL/ID #:
156AC8945(IA)
Customer #:
5283367
Name:
Ludy, Mark Andrew
Class:
D
ID Status:
None
Address:
1205 LAURA DR
Audit #:
6440266
DL Status:
VAL
TRLR 103
Issue Date:
11/02/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
10/04/2017
CDL Cert Status:
None
522451535
Endorsements:
3
CDL Med Status:
None
Mailing Address:
1205 LAURA DR
Restrictions:
NONE
Restriction
None
TRLR 103
Supplement:
Date of Birth:
10/4/1976
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522451535
History Information
Convictions
Citation Date
Conviction Date
ACD
Ex lavation
Count
]UR
02/04/2011
03/16/2011
IN50
I Improper Turn
Johnson
IA
03/17/2013
08/09/2013
IM81
ICareless Driving
Johnson
_
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Name: Ludy, Mark Andrew DL/ID: 156AC8945
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 IZWa Department
of Transportation to so certify. _ c2
C
In witness whereof, I have caused my signature and the seal of the Department to be set upon this G_ofurnent,..03 Ankeny.�%wa
this date: Can
r.�
;_y
%F, 1/11/2016
IOWA»$ D. a I/ }
t~Office» _mom m
Iowa Department of Transporation
Name: Ludy, Mark Andrew DL/ID: ,56A m<
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