HomeMy WebLinkAbout16-015IDENTIFICATION NO. ) U-0/
�2 s r' (Office Use Only)
7i'-r�—�
CITY OF IOWA CITYAPPLIC TION FOR TAXICAB I MOTORIZED PEDICl4' I.�' ORMRR
410 last Washinbton 51retl
(Police Department review must be made between 8 a.m. t�p�.'�Ond Friday)
�
Iuwa Cily. Iowa 52240-1826 Failure to com lete the "re wired" Information will result /n OT -the a[trsh'�ation
(319) 356-5040--,(..� 4a )
(319) 356-5497 FAX '�rT1 _V
First Mid le
1. Name (REQUIRED) / ' ' ,, '. C r LaS ry
2 Address (REQUIRED) - y(> / i ' /��/fir✓�{ /✓_LC W
3_ Contact lnformation(RECIUIRED) Email:C �� (2r<aC(IklU=�ellPhone;�
(AII written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) , ' /S 1 [
b_ Taxicab Business Name (REGUIREb)NAP, TA x1
5 Prior experience in transportation of passengers _
6. Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsewhere?
Tyne of offense
Where
When
What happened to the charge? (Circle one)
(AM Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
Tyoe of offense
What happened to the charge? (Circle one)
CCo�ted� Dismissed
Where When
Deferred Suspended Plead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? .
Type of offense Where
When
Have you ever applied to be an Iowa City taxi driver using a different name? If ves, piease provide the name(s)
DEPARTMENT OF CRIMINAL INVESTIGATION {DCI) REPORT AND STATE CERTIFIED
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
APPLICA'PON FOR IAMCAB VEHICLE DRIVER
Page 2
I hereby certify that 1 have issued�o me by the Iowa Department �of Transportation a� vali
] er [} ue /7 S issued on ,�/� expiring ion
e
falsely answer any questions in this application, that this application maybe denied, AgreeAdr6e that W7
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examireZ
documents relating to this application, and I further agree that, if authorization to be a taxicab drivcre
times with all of the provisions of Title 5 hapter 2, of the City Code. (Needs tozoo
i front e
Signature of Applicant Date1 }'
-rstaA"al if I
s appMtion, i
all r s and
gc co n at all
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STATE OF IOWA )
COUNTY OF JOHNSON ]
Subscribed
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 Chauffeurs license _0 t 1. t"5 12ct,�
�
�Afp,),ice�
Signature Chief or designee
_0 (,,-> IfI�
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,
Signature of City Clerk o
Office Use Only
Approved applicatirxr
DCI report
State certified driving record
Website update
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Sh+APTER I .UAFLR i (IISTOMER DRIUN
�VYwt1r:Y:va:.4'l�R:rwy;`
Inquiry Date: 674/2015
Name: Bickford, George Frederick
IV
Address: 401 9TH AvE
City/state: WELLMAN, IA 523569338
Mailing Address: PO BOX 296
Mailing City/Stat.: WELLMAN, IA 523550296
Convictions
Office of Driver set vices
PO Box 9204 s Des Moines, IA, 50306-9204
Phone: 415-244-9124 1 811G-632-11112! 1 Faz: E 15-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
DL/ID #: 700A]0622 (IA)
Class: D
Audit a:
7011629
Issue Date:
06/06/2013
Expiration Date: 01/15/2018
Endorsements:
3
Restrictions:
NONE
Date of Dirth:
1/15/1967
Sex:
M
History Information
Customer #: 6101512
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
xv.1c Conviction Date
11/23/2013 -. ... _.. 0.CD Explanation County 1Uf[
�.._ 99/05/2014 1592_
---Speed 7ohnson 're
Name: Bickford, George Frederick IV DL/ID; 700AIC627
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 officlal record currently In the custody of
said ofl9ce, and that I heve been authorized by the Director cf 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 data:
Name: Bickford, George Frederick IV DL/ID: 70OA30627
6/4/2015
=4-" 06'0�4
Office of Driver Services
Iowa Department of Transportation
�r Jun, Lll1.� UGr'Ni_ Ulv of ;rlrolnzl Investigation to. opal f. 11
, In, 4. _.. __ _._ �___ _, OB/09 /201L 10:£_ .,113 /662
(STATE OF IOWA
Criminal History ReeaKd Check
Request Form
ro:town DIVlsiouufcrinlioallnvestigation
Support Operaciung Bu rob u, 1"FFnor
215 C. 71" street
Des Moines, Iowa 50318
(515) 725.6066
(515) 725-6000 Fas
I am reuuesfino an loWa r'rirasiunl NiObIV RPCAM Check mt
DCl Account Number: _ 1 b 0
•— iif ryplitnblt)
From: SLiy of Iowil City
City Clerh's Office
4(0 E. Wasbing(on Stroct
Iowa City, IA 52340
Ph one: 319.356-6641
Fax; 319-356-5497
Last Name fnwwslog9
First Name, (namow )
Middle Name, (aminnacndan
Date of Birth mandato
Con d_err(mandaw
Social SecuritNumber (raeonnmodea
y
Waiver Injormalion: wilhou( a signed walver from the subject of the request, a complete criminal history record may not
be releasable, per Cede of Iowa, Chapter692.2. For completa criminal history record informtfon, as allowed by law, alwoys
obtain a waiver signature from the subject of the re uest,
Waiver Release: l hereby give perinhaien for Ibe above «glrstlng official la conduct an Iowa criminal hiaory record clunk nide du Division of Criminal
hwesUlaliml(DO). Any vimlml history ew concerning me dddw ismaintmAcd by the/ aybc rchatcdai allowed bylaw.
Iowa Criminal History ktecord Check Results - ', ,Dc,.;,tan,,.)
As of lP 5rS 171
a search of the provided rulme and slate of birth rever'lt�(�`.'
I (1 O
No Iowa Criminal Tlistary Record found with DCT o�
2 D iy
® Iowa COininal Hicmn' Record attached, DCI
Del 6lifials-- -6., -
0Cl-77 (06125/10)
Rtctived Time Jun. C 2D15 10:34AM No. 9635