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Home My WebLink About16-028IDENTIFICATION NO. (d— 0L� 1 l 1 (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICA13 VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (3 19) 356-5497 FAX 7First , ddle ' J L�$t 1. Name (REQUIRED) �i (Air\ j% Yea IC's 2. Address (REQUIRED) I I �C 1' C L .I _LL4 3. Contact Information (REQUIRED) Email: i 1 1' d ,CGV Cell Phone: ICI 27- S c(�� . (All writ en communi ation sent via email) 4a. Chauffeur's License expiration date (REQUIRED) r , 13 1 ' �ic "2 I /1 b. Taxicab Business Name (REQUIRED) I y lln ((G`> I c"X I ��` 5. Prior experience in transportation of passengers: IP 1yc-c K a T Allo rCC -� 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? _ice 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? What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Ity Other n 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? I \A, Type of offense Where When cs� 9. H ve you ever applied to be an Iowa City taxi driver using a different name? If yes, please pfovro'th€y DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED ' DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RFiVIEW.. r� 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 ereby certify that I have issued to me by the Iowa Depa m t of Transportation a v lid Chauffeur's license number P) i qC issued on C I Z C expiring on I understand that if I falsely answer any questions in this application, tat this application may be denied. I agre that in making this application, I consent to allow agents or employees of the Ci of Iowa City, Iowa, in their discretion, to examine any and all records and documents relating to this ap licatio , and agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provi ons o le 5, Cha or, of the City Code. (Needs to be ign d in front of a Notary Public) Signature of Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) �wbscribed and sworn to before me by f _n M T • C v on this / o day of h4�nrnn. -icvLe 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� Signature of Polila chief or designee Date AFTERAPPROVAL 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. Signat f -City Clerk or designee` Office Use Only Approved application DCI report State certified driving record Website update / Date Clerk/TAX1DR1VBADGEP.PPL92014amended.Doc 0312015 o2/([: -b. 12. 2016- 10:39AM Div of Criminal hvestigation,DCII No. 7229 11 1/1 1. NATE OF IOWA mi`wl • n'vl, 's Criminal History Record Check e a Request Form Y b To: Iowa Division ercrindnal laverlIptim Support Operatlems Bureau, l" Floor 21's F 70 Street Dm Moines, News 58319 (515)725.6066 (515) 7256080 Fal I am reauestina an Iowa Criminal History Record Check on: /r f�ft Nll�4 DCl Account Number. 05 -1r(- 'nw �^ Prappiiahk) + Front r„4rG.s aXl 1110 5�evc.s pr, Phonr. ,(31t ) 3511' ' Vise:. _ 1311 SSI - G I -m Name Twmw First Namemeode, 1 WdleName (r I Date of Birt mud.. Gender Social Security Number 1 2 41ak �Femak ,� LI - I (0 I Waiver J*rm do . Without a dvied waiver frees the subject of the request, a complete eNmmal htetory record ca my not be reteauble, per code ar Iowa, chapter 692x, For Puzaiple e erlmlam! hlltory record laformaflon, mm allowed bylaw, always le awaiver signature from the subject of the mucst, —� Walver Release:lbeift pia p-mk+ba for free e`afflq m In mwe wimerl hlmry nko,d rear w;lh We oivienn ofCfhfllnl b~1j&fbn(OC11. Anyatm11hiffayma ams dr I bAI&Au ,In y to 194"W u dlaeod by lew. Walver Sign I'. AV VW 21 %-1"M 1U,a11 ala LUA V 1.%1G4.1U11U 4LGe:A JMWO U110 -- Pa oto cetyl As of a J'a a search of the provided name and date of birth revealed- J No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, DCI #f - "" L.F. �'f J ,` ca Ct DCI initials Ki •- ICI -77 c -n Received Time Feb. 9. 2016 11:26AM No. 6942 CM Iowa Department of Transportation OfficedDriywSw ees (Tdl Flee) 8DO-532.1121 PO S92D4, Das Mmm, fA 5D3W92D4 515-244-9124 FAX 515239.1831 Convictions Citation Date Certified Abstract of Driving Record Ex lavation Inquiry Date: 2/14/2016 DL/ID #: 296AF8795(IA) Customer #: 2701866 Name: Kelley, Brian Patrick Class: D ID Status: None Address: 1520 TRACY LN Audit #: 8788593 DL Status: VAL Issue Date: 01/23/2015 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 12/31/2021 CDL Cert Status: None 522405832 Endorsements: 3 CDL Med Status: None Mailing Address: 1520 TRACY LN Restrictions: NONE Restriction None Supplement: Date of Birth: 12/31/1982 Mailing IOWA CITY, IA Sex: M City/State: 522405832 History Information Convictions Citation Date Conviction Date ACD Ex lavation Co 11 ]UR 05/26/2015 06/19/2015 M34 Followin2 Too Close I lohnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number ]UR 05/26/2015 860746 IA Name: Kelley, Brian Patrick DL/ID: 296AE8795 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 ra an official record currently in the custody of said Office, and that I have been authorized by the Director of the IovY2Department T of Transportation to so certify. � 1 In witness whereof, I have caused my signature and the seal of the Department to be set upon this docgrpent, attX NkenyIowa this date: G7 --A%Wl;(fN 2/14/2016 kl A N D. 0. T� "$ ".. a Office of Driver Services Iowa Department of Transporation Name: Kelley, Brian Patrick DL/ID: 296AE8795 Gr1 v 0 ^J� :J t Gr1