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HomeMy WebLinkAbout16-075IDENTIFICATION NO. / UI — 0 1 �1 (Office Use Only) 7r elllrMts'� APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday) 410 East Washington Slrecl Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX 7st Middle 1 Name (REQUIRED) 2. Address (REQUIRED) LLxGt CDl� lfrq 3. Contact Information(REQUIRED) Email: 0.f IIQ�Ir`L ell Phone: (A ritten communication sent la email) 4a. Chauffeur's License expiration date (REQUIRED) Z)' % - D b. Taxicab Business Name (REQUIRED) _ 0 -:2—` b. Q 5. Prior e pe//rriiQQJJen a in transportation of passengers: e p ���Q D� 6. Have you ever been arrested /charged with anyMgysdemeanors and/or felonies in this�State or elsewhere? T offense %e70r, e�t� N-S11'1�"IeS C-" yr/6 �o// L Where When C n vk e�w>a;'ne5 •�fv 5 -17 -ogall) W thappened to the charge?(Circle one) `/ r < < 6r' P? %?/ Convicted Dismissed Deferred 666 Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? —Ad 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? Z!D 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 the=name(s)„ DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED Fri DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW— You must apply for an individual Department of Criminal Investigation Report (form available upg_ri request). : I (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa De rtm nt of Transportation a alid hauffeur's license number Q -iS �7 issued on expiring on Q I understand that if I falsely answer any questions In this application, that this a lic tion may be denied. I ree t at 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 T' I 5, Chap r 2, of Hr5CCode. (Needs to be signed in front of a Notary Public) Signature of Applicant ct Date <xxxxxx���axxxxxxxxxx;.�,.;,�, �.��,..x�xxxxxxxxx>xxxxxxxxxxxxx.xxxxxxxx:xxaxxx�f«.�.��xx�...-rx.,,xxxxxxxxxxxx,xxx.xxx.xxx.,x.....,xxx.xx,xxx...xxx STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Gc L 1 , L7i,, on this i day of kA<: 1 I b! t o . 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 0 (Z4 G Date Signatur olice 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. Signature of City Clerk or designee 'f 7A�/G Date x+xxx+.rxxxxxx+x+xaxxx..Fsxx+sx�>ax:axax:ux:er:aa+xx,exx:xxxxxxxxxxxxxxxxxx=xxx+xxxxxxxxxxxxx.xxx+xxxxxxx:�xzx....x.x»..•...x:x..�«�+.x+xx.xxxxxxx..x.x Ca T Office Use Only Approved application DCI report State certified driving record Website update :3 t. CierWT XIDRIVBADGEAPPL92014...,ded.DOC 03/2015 o3/;Mar, 29. 2016,610:0206bDiv of Criminal Investigation (Fax)31933827 o, 0890 P. 4/6002 STATE OF IOWA �.s,,�,�: f•', rni�Crimifial History Record Check Request Formwd. Tor Iowa Division of Criminal Investigation Support Operations Bureau, 1" Floor 215 It. 7'h Street Des Moines, Iowa 50319 (515)725.6066 (515)'725.6030 Fax I am reaueatln2 an Iowa Criminal Ffiatnru Rennrrt Ch„ le nn- DCI Account Slumber: 9967-F pfapplleabN) Frame Yellow Cab ofXowa City P.O. Boit 428 Iowa City, IA, 52244 (319) 338-9777 rhonol Fox, (319) 339-7302 Lost Name mandato First Name (mandato Middle Name reaammegdod) Date of Birth mmdalory)�endde�e��(mandato SOCial•Securl Number marnmendod /Q RJMala ©Female t� Waiver Inf matlOnd Without a signed waiver from the subject of the regpest, a complete criminal hillory record may not he releasablo, par Coda of Iowa, Choptor 692,2, For commlate erllnlnal hislory•reeord Ihforma tlon, agollowed bylaw, always obtain a Walversl nature from thasub act of the request. Walver Release; l hereby give pmAtion for the above a ell amielsl ra a el an lova edmlasl haaatyracord chaekwlrh the D(vlrlon of Cominel lnvmtlsadon p3C0. Any criminal hmory data conaeming 111 Ilntafn be rejeued as /tlowetl by law. Walver Slkna r As of2-7 q�(, a searoh of the provided name and date of blah revealed: , Q No Iowa Criminal History Record found with DC1 Iowa Criminal History Record attached, DC1 iI �wr DCI initials DC1.77 (08/25/10) Received Time Mar, 27, 2016 2:34PM No. 0742 (Dol use anly) r, Mar -29. 2016 10:03AM Div of Criminal Investigation No -O690 P. 5/6 IOWA CRIMINAL HISTORY DCS 00550123 MISDEMEANOR CONVICTIONS ONLY PAGE I OF 2 DATE PRINTED - DCI :00550123 2016/03/29 NAME: BMITH,gARY LEE DOB SEX RAC HGT WGT EYE HAIR SKN POB 19581019 M W 500 230 BLU SDY FAR IL ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y CCH RECORD • i'+ 01 ARRESTED 19980815 AGENCY: IA0580000 LOUISA CO SO CHARGE NO- 02 IA STATUTE IA123-46 PUBLIC INTOX TRK#: 030959602 COURT DISPOSITION AGENCY: IA050015J LOUISA CO DIST COURT COUNT NO- 02 IA STATUTE: IA123-46 CONSUMPTION -PUBLIC INTOX CHARGE CLASS: MISDEMEANOR CONVICTION TRK#! 038959802 SENTENCE DISP EFF DAT FINE A17D COSTS PAY SURCHG 19980930 02 ARRESTED 20100517 AGENCY: IA0290000 DES MOINES CO SO CHARGE NO- 02 IA STATUTE IA123.46(2)-A CONSUMPTION OF ALCOHOL IN A PUBLIC PLACR 2 COUNTS TRK#: DA002VW02 CHARGE NO- 03 IA STATUTE IA719.1(A)-1 CONSPIRACY - 0001 TRK#: DA002VW03 COURT DISPOSITION AGENCY: IA029015J DES MOINES CO DIST COURT COUNT NO- 01 IA STATUTE: IA123.46 CONSUMPTION / INTOXICATION - 1978 COURT CASE ID: 08291 SMSM031717 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#. DA002VW02 _ SENTENCE DISP EBF DAT G� FINE $65 20110316 COURT DISPOSITION AGENCY: IA029015J DES MOINES CO DIST COURT COUNT NO- 02 IA STATUTE: IA719.1 (1)A INTERFERENCE W/OFFICIAL ACTS —':"✓ µs"�� COURT CASE ID: 08291 SMSM031717 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: DA002VW03 SENTENCE DISP EFF DAT FINE $250 20110316 Ma r. 29. 2016 10:03AM Div of Criminal Invesh gation DCI 00558123 PAGE 2 OF 2 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY HE RELEASED TO HON -LAW ENFORCEMENT AGENCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION Ow No. 0890 P. 6/6 DO T f. Office of Driver Services. PO Box 92+74 Des Moines. IA 50306-9204 Phone 515-244-9124 p. RO0-532-1121 I Fax 51` +39AP37 ww.w.irwace'..gov Certified Abstract of Driving Record Inquiry Date: 4/7/2016 DL/ID #: 707A38376(IA) CDL Permit Class: None Customer #: 747183 Class: D CDL Permit Issue None Date: Name: Smith, Gary Lee Audit #: 7984891 COL Permit None Expiration Date: Address: 956 BOSTON WAY APT 2 Issue Date: 04/16/2014 CDL Permit None Endorsements: Expiration Date: 10/19/2018 CDL Permit None Restrictions: City/State: CORALVILLE, IA 522413170 Endorsements: 3 ID Status: None Mailing 956 BOSTON WAY APT 2 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing CORALVILLE, 1A 522413170 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 10/19/1958 CDL Cert Status: None Sex: M CDL Med Status: None History Information Operating While Intoxicated Test Refusal/Test Failure Violations f: rcurrense ACU CxplanatSaO JUR 05/16/2010 Al2 OWI Test Refusal IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. A.ccie"t Date Case Number 3UP 03/31/2015.... ... - . 852459 IA .... Sanctions dype Ff�ective End t;co °�rplanation Occurrence3U,t ,JUP Revoked 05/27/2010 '.05/26/2011 IA12 OWI Test Refusal IA IA Name: Smith, Gary Lee DL/ID: 707AJ8376 m Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transporta{jon, dohereby 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 tNs date: vENiClfg��n,, ®1®®' 6�8®iy+ 4/7/2016 �' IOWA :s % CC' D 0. T. �. .Piu•.ra. +++th"9f®A13r Office of Driver Services