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HomeMy WebLinkAbout16-035► r �®n44t 114 ��1s cccmr Ya.ar._ CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319)356-5497 VAX 1_ Name (REQUIRED) IDENTIFICATION NO. ) I _P — (> j S (Office Use Only) APPLICATION FOR TAXICAB 1 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 First Last 2. Address (REQUIRED) (I [ �v t (1 �Z d ✓ q Ci� T fl 2 i k 3. Contact Information (REQUIRED) Email: emir s s ka rl G�w Cell Phone: (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) o/3v�z©zZ b. Taxicab Business Name (REQUIRED) YP11n t., Cn� r,F �owti (1 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Y�0 Type of offense Where When d �, .p /fb I"'167 d1 an fcati ( )-0 IAV, tti Oe rur-f (�P e c j Qh What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended leadGuil Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of p{offense Where When ""T"LRI`�� ir�t�F�L d���nJP 2 -Oil o �-( w do ✓1 SfF 1� �� U I� What happened to the charge le one) Convicted 1 Dismissed Deferred Suspended Plead Guilty Other, 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five yebrs? Type of offense Where When 00 ra ry 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provid�lheUme(s) IU O v s cs 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 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number L�3 OA Q 2_94 issued onI I expiring on 7L Q/3�1 Z . I 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant - Date f/ STATE OF IOWA ) COUNTY OF JOHNSON ) and sworn to before me by pr4j`" S on this ��_ day of VVENDY S. in and for the 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 Signature o 01 a hief or designee 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. tS J Signat of City Clerk or designee ate N axxxx�:�i.:tai:��.ted+�xksx.zx�<x�:t�xx:ttxlx�+rxrhxxi:xxx�.tx�>x>xxx+�-.exii+��ttx�+xr++ea:tax:txxtxxexxe�i:ka-kk�<+x-x<ez��:txtki.Wer:rxx+R �#:t:/:-.'.��,##.*Aei Office Use Only v 4 v Approved application DCI report P') State certified driving record U, I Website update r-> ClerW AXIDRIVBADGE PPL92014amended.DDC 0312015 en.lo. LUID II�Z9Am lily o Criminal Investigation No. 1908 Y. 3/h Fr..n, �., .y ur �uw.� �.i�y G16Yn vule.,b aim .esn Ggry/ 02/16/2016 14;30 0407 P.002/002 STAFF OF IOWA Criminal History Record Check Request Forin To: larva DivWon of Criminal $tvesllgali oil S^nplrnrt Operatim+s Bureau, 111 Floor 215 D, Ila street Des Moines, Iowa 50319 (515)725-6066 (515) 725-6080 Fan ail Iowa Last DCI Account Number; W c —J -- tirapplicoble)—_. From; CILry ofof 1o+v� CievCiey-� —Elly Cierle's Office m 410 F. Washington Street Iowa City, IA 52240 Phone: 319-3565041 Fax; 319-356.5497 `kLl sc,i D,,\( t,Voll Date of Slr(h (maudalory) Gendei' (mandatory) Social Seeari 'Nun 7 —3 b - I' ( �' 1 Efmale ❑Female Waiver InforUMffonr Without a signed +varver from the 511bf ect or the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For comnlete criminal ItWory record information, as allowed bylaw, ahvays obtain a waiver shenature from the enhlnel �f em..a...,..�e Wrtiver Release: I hcrcby give permission ror the'Jove rcquts(Inp orficial to conducl m loll adlnlnal history « cord check w'illl the Division of criminal bmve51i9Aan (DCI), Ally trihlinal biseory data concerning me (hal is maintained by Ute DCI may be releeced es allowed by law. U'aiver Signafnee; Iowa Criminal History Record Check Results- (DCI use only) As of a search of the provided name and date of birth revenled: No Iowa Criu»nal History Record found with llCI ❑ Iowa Criminal Histury Record attached, DCI it _ -- ,< 11yr� AJ -r, DCI initials_ j>ut T—_ N DCI -77 (02/25/10) Received Time Feb. 16. 2016 1:19PM No, 7495 CIowa Department of Transportation OfteofDrtrerSeem (Toll frae)# +a32-1121 PC) Box 9204, Gloss Moines, IA 5WE6-Id204 515-244-9124 RJB- 515-239,1837 Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 2/17/2016 DL/ID #: 230AD2948 (IA) Customer #: 5386301 Name: Jackson, Dallas Class: D ID Status: EXP Joseph White Address: 920 N GOVERNOR Audit #: 8858609 DL Status: VAL ST Issue Date: D2/19/2015 CDL Status: None City/State: IOWA CIN, IA Expiration Date: 07/30/2022 CDL Cert Status: None 522455920 Endorsements: 3 CDL Med Status: None Mailing Address: 920 N GOVERNOR Restrictions: Corrective Lenses Restriction None ST Supplement: Date of Birth: 7/30/1989 Mailing IOWA CIN, IA Sex: M City/State: 522455920 History Information Convictions Citation Date Conviction Date ACD JUR 12/02/2015 01/05/2016 F34 tExvationCount ing on ed Wa Johnson IA Name: Jackson, Dallas Joseph White DL/ID: 230AD2948 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. r.> In witness whereof, I have caused my signature and the seal of the Department to be set upon this document,`.aLAn keny, Iowa this date: r *"Y v 2/17/2016 i`^J a a t r.J Office of Driver Services Iowa Department of Transporation