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Home My WebLink About16-016I- -- fit CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 �4j 35.6-SO4t7``.� (3 19) 356-T497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. 1 LQ— rJ f t o (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 Last 3. Contact Information (REQUIRED) Email: /�,Lt'jyyf�'�t/fm/f- r�,,.t Cell Phone:�3i�19 (All wntten communication sent via email) �y�y 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) %' �/ Y2 &oi 5. Prior experience in transportation of passengers: $y'rs 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where I Ju What happened to the charge? (Circle one) Convicted Dismissed coiferrD Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Z(/e? _ 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? Al() Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the— iVJ DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE t t RTIRED W DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHII_F RWIEW,--�, ( You must apply for an individual Department of Criminal Investigation Report (form avail able' upon regapst). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) F\ 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I herebcertify that I have issued to me by the Iowa Dep rtTent of Transportation a valid Chauffeur's license number ssued on / al expiring on eS vaJ 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 cf 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 sig ed in front of a Notary Public) Signature ofApplica � �� Date 2� LA/fc STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by vjG,a., C_ Jl ; on this day of 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). cense 121 ra, L al/Z 1 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. 2&ir�L,.,/ k • �LGLS/ Sign"atvre of City Clerk or designee C�"2 O Dat N Office Use Only co r% Approved application na DCI report State certified driving record Ln Website update cie, W1DRivaAoGe RPL92D14aMeIded,Voc 0312015 Iowa Department of Transportation i 0 Woe CIT Gfwel Serwes (Idl l- ee) M 532-1121 PO Box 9204. DOS M01118s, IA 50 M 13204 515-244-9124 fAX 515,23x313537 Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 1/27/2016 DL/ID #: 288AE5480(IA) Customer #: 5342369 Name: Collins, Anthony Class: D ID Status: None Address: 1602 YEWELL ST Audit #: 8644200 DL Status: VAL zone Issue Date: 11/25/2014 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 12/05/2020 CDL Cert Status: None 522406000 Endorsements: 3 CDL Med Status: None Mailing Address: 1602 YEWELL ST Restrictions: NONE Restriction None Supplement: Date of Birth: 12/5/1972 Mailing IOWA CITY, IA Sex: M City/State: 5224D6000 History Information Convictions Citation Date Conviction Date ACD Ex lanation County JUR 10/01/2011 10/28/2011 S92 Speed (10 mph & Johnson IA under in 35-55 mph zone Name: Collins, Anthony DL/ID: 288AE5480 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: >v v�44 1/27/2016 c, Iowa Q. 0. Office of Driver Services - Iowa Department of Transporation CIi f'7 Jin, l9. 1616 3:23PM Div of Criminal investigation No, 55194 P. 5 FZn1:0Ity Or lawn CITY Mork Otrlkg 399 3666497 01/15/2016 13:91 Y/374 6.002./002 STATE OF IOW Criminal History Record Check �t l . Request I+ortn �)a '1'a: Iowa Division os-Ctimblal Investigation support Operations Bureau, 1'r Floor 215 f3.7d' $tree( Bas Moines, Iowa 50319 (515)725-6066 (515) 725-6000 Fax I am renuectiao an Iowa Criminal Hictniv Record Check on, DCl Account Number: y'w"� -F _ (if npplloable) From: City of Iowa City City Clerk's Office'' 41Or. Waslli igion Street Iowa Citv, IA 52240 Phone; 319-356-5041 Fax; 319-356-5497 Last Name onatidatmy) First Name (mandatary) Middle Name (rec9n,wenaed) Date of Birth mandaloh•) GOldd er (m�atory) Social Security Number recommended) Z' 1L3114a1e Female 21s2S-- WaV erin,% razation: With ou( a sign cd waiver from the sub)ect of the reques(, a complete crlmInaI history record may not be releasable, per Code of Iowa, Chapter 692,2. For c m lete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the recluiest. Waiver Release: i hereby give pamissian for illc above requesting official to conduct m, Iowa « Intinel history record check %yi1h the llivision of Criminal Invtstigarimr(DCD. Any cKminel hinory dola conuming me lhalis mainlahiedby die DC) oiayhtMeased os allowed by law. 'ray' Waiver Signafarere' I , I Iowa Criminal History Record Check Results As of LA a search of the provided name and date of birth revealed: ® No Iowa Criminal History Record found with DCI l C) Iowa Criminal History Record attached, DCI N tf � S" c � r DC1 initials loo— E; "L'1-rr (voizyrsv) Rprpivorl Timp Jan 15 7(116 1)AUM No 5470 L 5an.19. 2016 3:23PM Div of Criminal Investigation No5594 P. 6 IOWA CRIMINAL HISTORY DCI 00916489 NON CONVICTION PAGE 1 OF 1 DATE PRINTED - 2016/01/19 DCI:00916489 NAME: COLLINS,ANTHONY DOB SEX RAC HGT WOT EYE HAIR SKN POB 19721205 M B 605 200 SRO ELK DRK IL ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y CCH RECORD •'�* 01 ARRESTED 20101130 AGENCY: IA0520100 CORALVILLE PD CHARGE NO- 01 IA STATUTE IA706.2A(2)(B) DOMESTIC ABUSE ASSAULT CAUSE BODILY INJURY/MENTL ILLNSS TRK#: 1A00AOU01 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT. COUNT NO- 01 IA STATUTE: IA708.2A(2)(B) DOMESTIC ABUSE ASSAULT CAUSE BODILY INJURY/MENTL ILLNSS(SRMS COURT CASE ID: 06521 SRCRO92689 CHARGE CLASS: NON CONVICTION TRK#: IAOOAOU01 SENTENCE DISP EFF DAT DEFERRED JUDGEMENT $315 CIVIL PENALTY 201/0330 PROBATION lY 20110330 UNSUPERVISED PROBATION TO DCS DISCHARGED FROM 20111110 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIOATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY, DIVISION OF CRIMINAL INVESTIGATION +tea c+ C._ Cb - .. -7� � �Y7 di;