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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. i�-DCp�4
(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
First ��--
1'r
2. Address (REQUIRED) i" 0- f0
3. Contact Information (REQUIRED) Email:
communication sent via ail
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ 114-1
5. Prior experience in transportation of passengers:
Last
tst'�j�S
Cell Phone: 7
io -aq3�
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?._P 1)
Typeof 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?yt S
Type of offense
c4 9
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspe ded Plead Guilty
8. Has your driver's license or chauffeur's license been suspended or
Type of offense
Where
When
_T
\ Other
rs?
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide thme(s)
/t
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE�ERTIRD e'
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RE=VIEW -
You must apply for an individual Department of Criminal Investigation Report (form available uppr4 requek).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) _ res
02/2015
APPLICATION FOR
�TAXICAB VEHICLE DRIVER %
Paget 421W.r.19i
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
issued on expiring on . 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 provisi 5, Chapter 2, of the City Code. (Needs to be si nod in ront of a Notary Public)
Signature of Applicant Date `3 Z� I,
<*'WWW„k*1 W** WW, k, -1 11. .A*.kk*********kkkkk,.**k*********kk-****** .—I, *k.k
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by er rf , c— _x -,j . r=a�_rj `moi' on this 7-b 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 Chauff is �
license 31/ I 7
Signature of Police Chief or designee
_3/24b6
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.
ign ure of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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ClerWTAXIORIVBADGE PPL92014an,ended.00c 03/2015
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ClerWTAXIORIVBADGE PPL92014an,ended.00c 03/2015
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Ole,- _l,r lm l 11 .! 11 ve SI I€aI IOn 03/22/2016 1a:��m'U171 vs t'.-21J2/oo2
STATE OF IOWA N
' 1 C'd•itnina? History Record Check a
s
Request Yrctr Ila A
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_ ��
DU Aecoun( Number: lkc�l - F
(if applicable)
To: lolva Diviyion of Criminal Investigation Frora. eit ofluwa Cit
:Support operations Y,m•ean, i"Floor Y "�--._------
Cily Clerk's offiee.
215 L', 7"' street 410 L Waslbin ton Street
De: Moines, Iowa 50319---�--- ---
(Mr%) 725-6066 Iowa Ciel •,- IA 52240
(515) 725-6090 Fos ..—.-.-----
Phone: 319-556.5041
Fax; 319-356-5497
am re uesting an loI+'a Criminal I'l or Record Check on;
Lase Brame O„aldateiv) First Name (m Al __ lliiddle Name (roronm,enaea)
TD
))ate ofl3irtlr (manaalnn) Gender (n,andamryJ Social SeCarit� R'nmber recnmmcnaoa)
emale �Q
Waiver AfOM1,76017 Wi(hont a signed waiver front the subleot of (he request, a complete criminal history reoord may not
be releasable, per Code of Iowa, Chapter 692.2, For complete crhninal history record information, as allowed by law, alwoys
obtain 2. W2NO-SIVIlature from the whierf n{fhr .nmoor
— 16faiver Rele(ise,-111ereb3,givcptiilissionlorth,
Inve0ption(DCI), Any criminal hislory data conccryir
Waiver Sipattere:
M
oajeral toTbMucl w lows efimaiatliisiory rceotTei ab q'111, the pivl Sion I
ai d 6y the DO may be lalessed as allowed by law.
As of a search of the provided name and dale of birth revealed
1\10 Iowa C'rinllnal I-listofp Record found with DCI.
® low'a Criminal History /record attache
d
, DCl
DCl
DC:1-77 (08/25/lo) ---!
Received Time Mar, 22, 2016 2:08PM No, 0157
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