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HomeMy WebLinkAbout16-071CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319)356-5040 (319) 356-5497 FAX IDENTIFICATION NO. l 1,9 — : i_ (Office Use Only) APPLICATION FOR TAXICAB I 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 1. Name (REQUIRED) ri //11 2. Address (REQUIRED) 370 1 'A" 3. Contact Information (REQUIRED) Email: 4a. Chauffeur's License expiration date (R b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa (© rc C104ck2 II written commun 7 - Cell Cell Phone. _319 — %y- 7 fyj 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide th"ame(s) no DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTkI)-=D - DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW`, e. You must apply for an individual Department of Criminal Investigation Report (form available upTn request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) C�:) 02/2015 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? )/ 6 Tvpe 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? Y Q Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? h Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide th"ame(s) no DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTkI)-=D - DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW`, e. You must apply for an individual Department of Criminal Investigation Report (form available upTn request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) C�:) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby �e ify t at I have is ued to me by the Iowa Dep rtm nt of Transportation v lid Chauffeur's license number / 2P iY � 7�� issued on 70P�expiring on "y I understand that if falsely answer any questions in this application, that this ad lic tion may be denied. ag of f e 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-,�91hapter 2, of the qV gpde. (Needs to be signed in front of a Notary Public) Signature of Applica STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me byC_)1 f �,±r I W r i / . i cj on this _t�3 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). Expi0on license q /2 �l 24 Signat re of Po ice Chief 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. SignAttfe of City Clerk or designee 3 .314r� -- / Office Use Only to Approved application DCI report State certified driving record' Website update cl C eVrAXioRiveaocEAP PL92maamen&d.00C 0312015 cC Iowa Department of Transportations Office ff [lffrel � (Td! flee) OW -632.1121 PO BOX 92134, FSS MMM, G4 5L830"22U4 515-244.9124 FAX 515-239-1837 Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Certified Abstract of Driving Record JUR Inquiry Date: 3/28/2016 DL/ID #: 769YY1758(IA) Customer #: 1272105 Name: Lettish, Christopher Class: D ID Status: EXP 02/13/2009 John D53 Non -Payment of IA IA Address: 3701 2ND ST TRLR Audit #: 8934357 DL Status: VAL 2 03/04/2009 12/21/2009 D38 Fail to Post IA IA Issue Date: 03/18/2015 CDL Status: None City/State: CORALVILLE, IA Expiration Date: 04/24/2023 CDL Cert Status: None 522412795 Suspended 06/02/2009 03/15/2012 D53 Endorsements: 3 CDL Med Status: None Mailing Address: 3701 2ND ST TRLR Restrictions: NONE Restriction None 2 Supplement: Date of Birth: 4/24/1979 Mailing CORALVILLE, IA Sex: M City/State: 522412795 History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 12/22/2008 480109 IA Sanctions Type Effective End ACD Explanation Occurrence IUR 7UR Suspended 02/13/2009 03/15/2012 D53 Non -Payment of IA IA Iowa Fine Suspended 03/04/2009 12/21/2009 D38 Fail to Post IA IA Security for an r -a Accident Suspended 06/02/2009 03/15/2012 D53 Non -Payment of IA Iowa Fine - _... ,.n �O Fi Name: Lottich, Christopher John DL/ID: 769YY1758 _ -x Cta -- Pursuant to Iowa Code §321.10, I, 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, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: 3/28/2016 IOWAIIra .s. Y } Office of Driver Services Iowa Department of Transporation Name: Lottich, Christopher ]ohn DL/ID: 769YY1758 Mar.23. 2016 9:29AM Div of Criminal Investigation No, 0214 1/1 Fr-...._.,- _. ,._ _..I Cl c,- _...-_ _— 03/18/20le 16:,- .163, . ,....2/002 lr fI GL^r IOWA f /. Criminal! Request Form Tu: Iowa DiVisiwr of Criminal Investigation 5'upport Operations Our eau, 1" Float - 215 C. 71.. Street Des Moines, Iowa 50319 (515) 725-6066 (515)725-6090 Fax I alll retluestina an Iowa Criminal Hki—mv Renard (lhe.clr my DOAccoun(Nunber: 1���) F__ (if applicable) From:Cit o(�C L...... -- City Clerk's office Oto E. Washington Street lolva City, IA 52240 Phone: 314-356.5041 _ Fax: 319.356-5497 Last Name (mindalory) First Name (loandwary) Middle Name (Moal,orneed) Da to of Birth (manda(o y) Gender (mandatory) Social 8eCUI'1 ' Number (recommended) M-79_ ®I!'fale ❑Female I I — 0 q— / Walvet'InfOrmatioll. Without a signed waiver from the subject of the request, a complete criminal history record may nal he releasable, per Code oflowa, Chaplet - 692.2. For co- mnlete criminal history record informadoii, as allowed by law, always obtain a waiver signature front the sub'ecl of the request. Cl/aiver Relefise; k bercby give permiuion for Ilre above requceling oificlal 10 eondud an Iowa criminal Illflaly Taco/d cheek wilh um Division of Criminal hnmsligal1011 (DCI)- Any criminal Wtory data eonceniug me 11181 ,5 main y the 1)C) may be released as allowed by law. r T4/aiyerSi„oltaffsre � -- ' Iowa Criminal History Record Check Results M of. _ 3 / a search of (he provided name and date of bird) relrealed: f J No Iowa CrimiOal History Record found with DCl ;r l. jjj ca ❑ Iowa Criminal History Record attached, DO 4 _e f DO initials Received Time Mar, 16. 2016 3:36PM No -0002 (DCI use onl))