HomeMy WebLinkAbout16-049CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1, Name (REQUIRED) _
IDENTIFICATION NO. ) � ` 0
(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
2. Address (REQUIRED) I5 d
r4/ SZZYtJ
3. Contact Information (REQUIRED) Email: pkv Cell Phone: 0-5-41-e`l3 %
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) Q 3 / 5// 2 D / b
b. Taxicab Business Name (REQUIRED) /y7,^/Z7 S 1 -x-,
5. Prior experience in transportation of passengers:
Last
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? -4111'Q
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? ye S
.N� Vi UlIZ11= r Where
When
What happened to the charge? (Circle one)
Convicted ismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? y e S
Type of offense / Where
n
When e
(2-16 �lG/
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prpyde the name(s)
/Vo
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 here`b� ify that I have i ued to me by the Iowa Dep giant of Transportation a valid Chauffeur's license number
7 Z Z %G issued on D1 /1 //to/6expiring on 6 5�5/�Ic/L 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 infrontof a Notary Public)
Signature of Applicant —:/ / `— Date
STATE OF IOWA )
COUNTY OF JOHNSON 1
and sworn to before me by,�} z �Q ) j} ��� a S on this day of
.�.�
Public in(bnd for the State
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� 6 ?i3
Signatur o ice Chdl/ 1ef or designee
:V612 -6)-t.
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.
Signa a o- Ftr f City Clerk or designee
Pate
Office Use Only
Approved application
DCI report
State certified driving record
Website update
cierarrPXIDRI BADGEAPPL9214amended.DOG 03/2015
0
cierarrPXIDRI BADGEAPPL9214amended.DOG 03/2015
031(Mar 2, 2016 10: LOAM
Dlv of Criminal Invasfigalion >DCI Iotf,No.8110
STATE OF IOWA
Criminal History Record Check
Request Form
Tot Iowa D"%a orcriwwal tovemigaden
support operations Bureau. I" Roar
216 R. 7" Street -
Do Moln", Iowa ;0319
(510) 72"w
(516)725-6D60 Fax
DCI Account Number,
(Irsrol e
Promt 4'fY09 Axl
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rb.(Fnz; . - 319 551
Last Name First Name wmlrw.v)
Mniddle Name nswnw mord
Date of Birth wwmu Gender ,,-dela
Social smurity Number
Q 3 l �f OI I °l Y ✓i�Male (]Female
� � 9- �Y �o �r 3 `�
Wolver lnformadon: WMhout a elgeed watvel Mem the subject of the request, a complete cM01131l hlemry rward may uet
be reteamble, per Code of Iowa, Cbaptsr 692.2. For cylook crtmlaal history record luformatloo,"agewod bylaw, Always
obtain a waiver a amre h•om the mb ret f lbs aL
Waiver Release: 1 ha0br,i.e paMuM tar dw oWmmr.61a onw 10 mdom N 1ew0 Ariz" hbwry r ;d sheet wl:h 04 Dlr1010e otcrimcvl
InrosdpllM (nCq. Alp' piM0e1 hOkry dLs 000rwe!%,a0 dw, 10 m,hMr/l�O�eby�/do [!CI mq hu mleued u Vlo� by IOw.
Walver.slBnatar6:
loww Crimlaal Histea Record Chech Results locleeee�yl
As of 'M , a search of the provided name and date of birth fuvoalad:
10.�t No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record ellsohed, DC1 µ
_ va
DCI inlllals;:
X1.77 (08(25/10) N
Received Time Mar. 1. 2016 3:08PM No. 8637
010WADOT .
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SMARTER [ SI�iPL€R 2 CUSTOMER i�R#YfN+.,�x;.�,n,..�._,r:
Office of Driver Seryices
PO Box 9204I Des fA roes, IA 50305-9204
Prove, 51`5-243-9124 1800-532-1121 I FaK.515-239-1837
wwfv.iowatlol:gox
Certified Abstract of Driving Record
Inquiry Date:
3/1/2016
DL/ID #:
433ZZ8765(IA)
Customer #:
2169524
Class:
D
Name:
Thomas, Andrew Aaron
Audit #:
9823115
Address:
1505 PLUM ST
Issue Date:
03/01/2016
CDL Status:
None
Expiration Date:
03/30/2023
City/State: IOWA CITY, IA 522402123 Endorsements: 3
Mailing
1505 PLUM ST Restrictions: Corrective Lenses
Address:
Restriction None
Mailing
IOWA CITY, JA 522402123 Supplement:
City/State:
'
Date of Birth: 3/30/1987
Sex:
M
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit -
None
Expiration Date:
County
CDL Permit
None
Endorsements:
1414 Fall to Obey Traffic Sign/Signal
CDL Permit
None
Restrictions:
06/26/2013
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Citation Date
Conviction Date
ACD Explanation
County
IUR
11/03/2011
12/13/2011 _ _
1414 Fall to Obey Traffic Sign/Signal
]ohnson
IA
77/30/2013
06/26/2013
Improper Registration
Johnson
aA
Sanctions
Type Effective End ACD Explanation Occurrence IUR 1UR
Suspended '11/20/2013 12/03/2033 D53 Non -Payment of Iowa Fine IA IA
Name: Thomas, Andrew Aaron DL/ID: 433ZZ8765
Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, 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, 1 have caused my signature and the seal of the Department to be set upon Ihls document, at Ankeny, Iowa this date:
_�31F.....
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30ti�-•:45-
IOWA
3/1/2016
O. T.
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Office of Driver Services
.�.,.�—
Iowa Department of Transportation
Name: Thomas, Andrew Aaron DL/ID: 433ZZ8765