HomeMy WebLinkAbout16-052CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52 240-1 82 6
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO._ / � 0 = 05-Z
aS0 (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)
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3. Contact Information (REQUIRED) Email. L
(All w
4a. Chauffeur's License expiration date (REQUIRE�E
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b. Taxicab Business Name (REQUIRED) 'g'1
5. Prior experience in transportation of passengers:
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n communlcation sent via email)
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6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /J
TVoe of offense Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
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KA
Where When
oto t r, }„h 3 //0
What happened to the 9harge? (Circle one)
Convicted Dismissed Defe d
/;
rre Suspended Plead Guilty Other _
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? VI U
ape of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro id sthe q w. r`me( _�
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW "Y
You must apply for an individual Department of Criminal Investigation Report (form available upon quest).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
Z6, U,
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I he certify th I have issued to me by the Iowa Dgpartment of Transportati n a valid Chauffeur's license number
� ce ly y s issued onll/0,Z expiring on _101011,,17 . 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 prov' ' ns of Title 5 of the City Code. (Needs to he signed in front of a Notary Public)
Signature of Applicant Date
�� l(J� 5
STATE OF IOWA )
COUNTY OF JOHNSON 1
Subscribed and sworn to before me by M ct Lu
)ci. -I a-.
on this 5 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 .
Expiration date of Chauffeur's license f z D
�I16
I. Ak4-4) —
Signa o o t e Chi&f 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.
Sigmkture of City Clerk or designee AJ
Date
Office Use Only
Approved application _
DCI report -,
State certified driving record
Website update 4
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To: Iowa Divisieu orcriminal [n res[ig'&timr
vupport Operation, Iiureafl, 1" Floor
z15 )r. 7"' Street
D*Moiues,imva 503]9
(515)728-6066
(715)725-609(1 Fax
STATE ATE Off' IOWApt
History Record Check �0
Request F(II- t
7aC1 Accqunt Number: l wd - x-
V (if opplicable)—�
Frur Ci, Al to -Lay
city Clerk's Office —
410, washiu ton street
lows CHI',1A 52240
Phone: 339-3;6-5041
Fax: 319-356-5497
uu nstm an Iowa Q'iminal Histoly Record Check ow
Last Maine (1110dalo,y) First �a n1B (meudalo y)
iddle. Near a
L(recanmundetl)
Date Of Birth_ Y Ge (n,anaalo,y)
Sec/ial 3ecaril� Nutrtber (recammenac(
pmale �Feutale �j V C
r'!rllivPr IrfoYlnalfDlt; Without a signed waiver from the subject tribe request, a c--�—�—
be releasable, Per Code of Iona, Chaptcr 692.2. For curl le[e crim- t'mplete criminal history record may not
obtain a waiver A nature from the sub'ect of t "�' lnnl history record inrormation, as allowed by law, always
�I hel'equest.
F3/(fiVBr XDC:J). Any
Imletrgive n,yd,l9idn for fhe-abeve requesting official rv""0'40 an Yo,va crimidol hisVaq record plreek will) rhe Division of Criminal
Itecsdgeliou (DCh. aty criminal history dila ern eernMg o,e lhal, a,ne Ile
_�7 y 1 DCl may uc releasca ar wed byJur:— �"
As of
H%river
- -.. I,. �..ih l'eeefaled
pAro 10%Va Criminal History Reem'd fouled vvl[!t rICI
Iowa Liminal History Recoi(I attached, DCI #
Del initials —k.
DC] -77 (08/25/10)
RerpiPPlI Tim, lac 17 VIA q G7Ph4 Mn f,ldl
(Act uip onyx)
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Iowa Department of Transportation
p Wt & tlrs�ef #;rllmces (tgill Free) CD4 5;52 1521
RD Box, X3204, Dc-, Rias 1A 513 06 rl 04 616 244.9124
SAX' 515 239 1831
Certified Abstract of Driving Record
Inquiry Date: 1/11/2016 DL/ID #: 156AC8945 (IA) Customer #: 5283367
Name: Ludy, Mark Andrew Class: D ID Status: None
Address: 1205 LAURA DR Audit #: 6440266 DL Status: VAL
TRLR 103
Issue Date:
City/State: IOWA CIN, IA Expiration Date:
522451535
Endorsements:
Mailing Address: 1205 LAURA DR Restrictions:
TRLR 103
Mailing IOWA CITY, ]A
City /State: 522451535
Convictions
Date of Birth:
Sex:
11/02/2012
CDL Status:
None
10/04/2017
CDL Cert Status:
None
3
CDL Med Status:
None
NONE
Restriction
None
Supplement:
10/4/1976
M
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date Case Number JUR
12/16/2013 1783844 IIA
Name: Ludy, Mark Andrew DL/ID: 156AC894S
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 1 have been authorized by the Director of the }pSya Department
of Transportation to so certify.
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In witness whereof, I have caused my signature and the seal of the Department to be set upon this documentfj. Ankenj';%wa
this date:
1/11/2016
IOWA 4,
D...1_"
Office of Driver Services
Iowa Department of Transporation
Name: Ludy, Mark Andrew DL/ID: 156AC8945
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