HomeMy WebLinkAbout16-084CITY OF IOWA CITY
410 East Washington Sirccl
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. 1l —og
(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: Kj'AO pi /i , �) hA , t�.Cox Cell Phone:
(All written communica ion sent via email)
4a. Chauffeur's License expiration date (REQUIRED) S - 2 I - aO �z
b. Taxicab Business Name (REQUIRED) _ �f 1 10(A)� a b t'i Towa U4LA
5. Prior experience in transportation Of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /yr
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? Bio_
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? _#6-1
Typeof offense Where When
77
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the Yame(s)
1Y DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED .f
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
DO o1R Raz -) O issued on!� -al - I(. expiring on � -�I-1 j9 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 the City Code. (Needs to be signed in front of a Notary Public)
Signature ofApplicanz�% a.Date �4 �1- I(
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by S0.LL.L U 4 1% -T ( on this �_ day of
T
y S APER Notary Public ii and for the State o wa
con
ysgn Fxl„res
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 Ww ?-4
Signatu f Police 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.
SignatTre of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
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ate
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Criminal i� CG{Otil(jt` .LIIHistory
Record CheeR
STATE
Request Form
DC7 Account Number: _9967—F
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TO: Iowa Division orCrlminal investigation
Support Operations Bureau, I" Floor From: Yellow ab of low$ Cf
215 S. 7" Street P.U. BOK 428
Dos Mo)nor, town 50319 Tows City, IA, 52244
(515)725.6066
—(S) -5)'725=608o Fay
(319) 338-9777
Phone:
Fazl (319) 339-7302
on
7 O N& Information: Without a signed we Ever from the subloet or the regpest, a complete criminal history rec�Ynayjyio(
be releasnble, per Code of 1owo, Chapter 692,2, For eomurete crlmina! hlstory.rewrd information, n8 allowed by
Obtain A waiver s1zhature from the subleer nrthn .�..,,,se
WaIV2rP616arel I hereby give perm ltIon for the above requeeling olYiolel ro eondueI&A (own arlm In el hhlory record AOak WEl the olvhion OfCrlminel
Imcalfgelion (DCO. My oAminnl hlrrory dela oanoeming me Ihel IS melnu id qy the DCt nu be releefcd of ellowee by lew�_
pYaluer Slgnarural
Iowa C`"riminal H' to Record Check Results (DClus* only)
As of y q , a search of tho provided name and date of birth rovcaled:
No Iowa Criminal History Record found with DCI rr
I 1'i
L JJ L:iI
❑ Iowa Crfminal History Record attached, DCI4 F"
TI
DCI initials
DCI -77 (08125110)
Received Time Apr, 18.-_ 2016 10:30AM N10.2021
Inquiry Date:
Name:
Address:
City/State:
Iowa Department of Transportation
fYnce of 0nocir :,ernes rice) Mi 51 r 1 t"1
PCi Bh:e 911W, Dm, Milffh dA %I 06 9204 1_.15 244 412d
I ,kX 51�. �9183''
Certified Abstract of Driving Record
4/18/2016
Terry, Samuel
Andrew
2305 ISETr AVE
MUSCATINE, IA
527614638
Mailing Address: 2305 ISETT AVE
Mailing MUSCATINE, IA
City/State: 527614638
DL/ID #:
002BB2520 (IA)
Customer #:
4465405
Class:
C
ID Status:
EXP
Audit #:
5940922
DL Status:
VAL
Issue Date:
04/24/2012
CDL Status:
None
Expiration Date:
04/02/2017
CDL Cert Status:
None
Endorsements:
NONE
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
4/2/1988
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Terry, Samuel Andrew DL/ID: 002BB2520
Pursuant to Iowa Cade §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'.
4/18/2016
10 WA
D. 0.T s
I _
11�hs,'i Office of Driver Services
^+rMws- Iowa Department of Transporation
Name: Terry, Samuel Andrew DL/ID: 002BB2520