HomeMy WebLinkAbout16-072CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
t319) 356-5497 FAX
I. Name (REQUIRED)
2. Address (REQUIRED;
IDENTIFICATION NO. / UO— Z
(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
3. Contact Information (REQUIRED) Email: h, i - Cye 11Iam V1,y it 09-yec 9' Cell Phone:
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) I I -0 - l
b. Taxicab Business Name (REQUIRED)
Prior experience in transportation of pa
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?V�
Type of offense Where When
-Phe.i�k 0 OCA -I[ !-r A 9L00z
What happened to the charge? (Circle one)
onvicte Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
r
Type of offense Where When
What happened to the charge? (Circle one)
Co e Dismissed Deferred Suspended Plead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? E
Tvpe of offense 1 Where
t�t When
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P^^i(�PYI� Ilaactl�iLOleT t'Ltf0j1ge— / 1(a65s)-01 00-n �a,/per
511�ivv AZ �rkC—,,"II�(9r ✓m .- NA ID
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the�4ame(s)!-,
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE EERTIFXD
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REV IEW';_ „
You must apply for an individual Department of Criminal Investigation Report (form avaitable upplt request).
rn
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
f
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
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 provisions of Title 5, Chapter 2, of e City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant 1`t ' Date
******k*****xxxx***=£***F*rt**k**k*h*£kk*kkk*x***fr***x*xz***********=***x*******************************zx**********kkkF+x*kk££*k**h*xFh**k**fr***
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 1=� ��� _ rip �i�.� on this J� day of
A � A -r i Z0/ Lo.
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).
of
license
I
Date
Police Chief or designee
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.
Signatm-6-of City Clerk or design e
nA I/
Date
ra
Office Use Only J
Approved application
DCI report w .0
State certified driving record
Website update
ClerYJTP IDRIVBADGEAPPL9 014amended.DOC 0312015
F,Aor. 1. 2016„11;16 AMoie,Div of Criminal lnveehgahon 03,&„20,c ,,,•No. 1303„6P� 2/2zJoo�
ll
STATE OF IOWA
Criminal History Record Check
Request )�oro.i
'1'0; Iowa DiVision of Criminn) investigation
Support Opera(€uns Bureau, 1'r Floor
215 C. 71ll Street
Des M(lilM, Iowa 50319
(515) 725-6066
(515)725-6080 fak
1 slu requesting an Iowa
UCr Accoult Number: __Li Cno -r
(ifarplicablc)
f>rom: City u,flowa•_—
city Cleric's Office ^- ---
410 E. Washin Ion Sheet
luwo City, lA 52240
Phrase; 319.356-5041 _ y—
Fas: 319-356.5491 ��-
----�=..�.•r _ +.3auul,e ivaple (recomnsended)
w v\ --
Date OIf Birth(maadalory) Gender (mandam y) Social Securit Nulnher (meommended
1 4 ` ~ l O- 0 ❑Male
Waiver irtfor%trfti0rt; Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Ionia, Chapter 692,2. Por com�lele criminal history record information, as allowed by late, always
ubjectofther
obtain a waiver slgnoturefrom thesequasi.
W(fiver Release: l hereby give rcrllission for the above reuasGn official 10
In1•esligatim, (DCI). Any criminal Lisluq�dala concerning me ilial ma(mai ed by the DCO ma Iowa
be rcleesed aistallon d6y lawl1cet hlhe Division vfLYiminal
4
waiversignature
Iowa Cri>ininal 1FTistot A2ecord Check Resl�tts :''..- 0-�
.. (llCl use mdy)
Aso['a
search of the provided name and date of birth rsvealed: N
No lova Criminal l'listory Record found with DCI - a •... W,
Iowa CKiminal 1-lislmy Record attached, Del II a 1
DC! initials_
DCI -7-77 (08/2.5/)0) -- _--_—_— -----_----
Received Time Mar31. 2016 iL 36AM No.1195
#gov CA v
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ut ^.rr °, r., !f 1,. �, 4i -`..A21 a ��=•-L?: k7c.i
lA'ti24`_ .1W'eat;O. Q:b`
Certifie4 Abstract of Driving diacnrd
History Information
Convictions
,m'etien
CIte3lcn axes _. ._.. �..
,12/31/2012. 03J16/2013 6a i 1 a. 'l'ri MarsOall 'U
Accidents - Accident involvement indicated does NOT mean the indixidual wo,' at fault rr giren a citatioe.
IUK
Aictlent Date
....... 5.9.1 1A
Sanctions
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£F aU:xe zh l AC, S t `-C. 9s ce ]=,.Y_ JUR
•- � ��/nPnnli 11/23/2915 D$] Il n Y y!I` Ir v, 4:.1" _._ IA
Name: Franks, Hydie Ann DL/ID: 803x¢7736
Pursuant to lows Cade §321.10, I, Mensa Sli eget, Director of OrFics of 1 - SP" e tn. Lepart f T- j,rfA1,,I do hereby flrbf that I an z_dnt I by e cuOslrector of the Iowa es pertinent of
held by the
Office of Driver Services, that this is a true and adcarate Copy of an official iem,d a frently It the eUtD )y or.a : :fl s rl that I h e
Transportation to so certify.
In winless whereof, I have caused my signature and the seal of the Depa, bnInt to b_ ;It op01tl u`;III ' 911nt, W 0.r 4c , towa [his 111^
u4ai......`�
OL/ID 0.
RO;zz%I3[, lla;
CDL Permit Class:
None
inquiry Date:
3/3012016
CUL Permit issue Date:
None
Customer Pi:
4020149
Class
D
CDL Permit Expiration
None
pl Af.• J.
Hydra Ann
Audit ffi
96t0a 60
1 E�ea.t,.,ntm lr.nsaI'ternlr
It
Name:
Franks,
r�
Name: Franks, Hydie Ann DL/ID: 803¢/773[
Data:
r..l
Date
CDL Permit Erdorsemants:
None
AtltlreSsc
4183 DANE RD SE
Issue
asstric[1ons:
None
Expiration Qats:
lll ID/2916
CDL Permit
ID status:
VAL
City/State:
IOWA C1 n, IA 522408510
i ndurseral
3
Mailing Address:
4183 DANE RD SE
Restrictimrs!
NONE
DL status:
VAL
RostriR,on
Nn,
CDL 5Wiv2:
Nene
Supplement-.
COL Permit5tatus:
ELG
Hailing
IOWA Clfy, IA 522408910
City/State:
CDL Cert ?lotus:
Nnne
Data of Birth:
11/10/1986
CDL Med Status:
None
Sex:
F
History Information
Convictions
,m'etien
CIte3lcn axes _. ._.. �..
,12/31/2012. 03J16/2013 6a i 1 a. 'l'ri MarsOall 'U
Accidents - Accident involvement indicated does NOT mean the indixidual wo,' at fault rr giren a citatioe.
IUK
Aictlent Date
....... 5.9.1 1A
Sanctions
F--'P
£F aU:xe zh l AC, S t `-C. 9s ce ]=,.Y_ JUR
•- � ��/nPnnli 11/23/2915 D$] Il n Y y!I` Ir v, 4:.1" _._ IA
Name: Franks, Hydie Ann DL/ID: 803x¢7736
Pursuant to lows Cade §321.10, I, Mensa Sli eget, Director of OrFics of 1 - SP" e tn. Lepart f T- j,rfA1,,I do hereby flrbf that I an z_dnt I by e cuOslrector of the Iowa es pertinent of
held by the
Office of Driver Services, that this is a true and adcarate Copy of an official iem,d a frently It the eUtD )y or.a : :fl s rl that I h e
Transportation to so certify.
In winless whereof, I have caused my signature and the seal of the Depa, bnInt to b_ ;It op01tl u`;III ' 911nt, W 0.r 4c , towa [his 111^
u4ai......`�
ter.
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C. `. C.�
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1 E�ea.t,.,ntm lr.nsaI'ternlr
It
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Name: Franks, Hydie Ann DL/ID: 803¢/773[
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