HomeMy WebLinkAbout16-093CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319)356-5040
(319) 356-5497 FAX
IDENTIFICATION NO
i cl
(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
V .irstr� -Middle
1. Name (REQUIRED) 2 Y r z'� U7 .�
2. Address (REQUIRED) J 0 ) q V o
3. Contact Information (REQUIRED) Email: S- rAG (�. ca
y Cell Phone:
Q V
(All written communication sen via email)
4a. Chauffeur's License expiration date (REQUIRED) h A- f
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? KcC
Type of offense Where , When
A,1
7
What happened to the charge? (Circle one)
Convicted Dismissed
Deferred Suspended Plead Guilty
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense n Where
/ 010
What happened to the charge? (Circle one)
Convicted Dismissed
Other _ a(I
When
a " Ii Ao
F.�
Deferred Suspended Plead Guilty .'Other_
Has your driver's license or chauffeur's license been suspended or revoked in the last five years'?.'
Type of offense Where When
Za ,-
9. Have you eye[ applied to be an Iowa City taxi driver using a different name? If yes, please provide the hame(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
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)
02/2615
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb certify �I hyve_issued to me by the Iowa Dep met of Transportation a vali Chauffeur's license number
C� r f / l ! S issued on ` / expiring on z Z / �' , I understand that if I
falsely answer any questions in this application, that this a plicat' n may be denied. 'agre 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 of Title 5, h/ap�er 2, of theCityCade. (Needs to be signed in front f a NotaryPublic)
Signature of Applicant���20��n
STATE OF IOWA )
COUNTY OF JOHNSON
Subscribed and sworn to before me by ek on this Z�— day of
a --
,� WENDY S. MAYER
w
-r _�
Iowa
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.
Signature of 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.
Signatbre of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
t baa/0
Date
aerWlAxIDRwaADGEAPPr92014.mended. Doc 03/2015
C410WADOT
SIHARFE i l alit€R'V'F I C�9S7�'4�€ � DRIVEN
NL+�il�tttO L�Cti7� t�V
Off -ice of Driver Services
PQ Box 3274 i Des hilbyrtes, IA !Y0336-42134
Phoria: E -15-244-P124 3 8GG ;32-1434 i 3aI: 51,2Y5-1337
Wawe_iowadot_tr34
Certified Abstract of Driving Record
Inquiry Date:
4/27/2016
DL/ID #:
701WI753(IA)
CDL Permit Class:
None
Customer is:
2857327
Class:
D
CDL Permit Issue Date:
None
Name:
Madden, Patrick George
Audit #:
8757468
CDL Permit Expiration
None
Date:
Address:
3009 12TH AVE SW APT 102
Issue Date:
01/13/2015
CDL Permit Endorsements:
None
Expiration Date:
11/22/2017
CDL Permit Restrictions:
None
City/State:
CEDAR RAPIDS, IA 524041460
Endorsements:
3
ID Status:
None
Mailing Address:
3009 12TH AVE SW APT 113
Restrictions:
Corrective Lenses
DL Status:
VAL
Restriction
None
CDL Status:
None
Mallin 9
CEDAR RAPIDS, IA 524041459
Supplement:
COL Permit Status:
ELG
City/State:
Date of Birth:
11/22/1950
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
ittrio Date C.rvwt,on Dow, ACHY Exp anavon Coenty I U F.
05/03/2013 SOS/30/2013 M42 Improper Lane (changing lanes) Johnson TIA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
touddeet Date
Case Sun' 6er
15/032013 -..
]3]]66. _. _._.
.,.... ._..
,.. _ ..... .. - _.
'IA
.1/03/2015
x.887389 ._ .....
,..
....._ IA
Name: Madden, Patrick George DL/ID: 701YY1753
Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby cel that I am the custodian of the records held by the
Office of Driver Servlces, 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 data:
.811/
IOWAEV
'ey
4/2]2016
�n
Z1......Office
111110Aortation
of Driver Services
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Mvti
low. Department of Trans
P P
Name: Madden, Patrick George DL/ID: 70IW1753 JJv
v11L'1zFviCab uiv 01 Criminal Invesfigafion
(Fex)3193362No, 2 18 8 P, 2/2V002
Cri {; R il`;G;iTtiI /
... "I HiStOrYRecord
.r,.,...::Request Form
I)Cl Account Number:, 9967-F
701 town Division ofCrtminalInvestigation (lfapplfaabla—)
Support Operations 8urcau, I" ploor Fromt Yellow
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Dos Molncr, lewd 50329 1'•O. Hox 428
(sty) 71.5.6066 Iowa Cl
(515)'725-6080 rax tya Tr1, 52244
(319) 338-9777
Phone;
FAXI (319) 3-39-73-02-------
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39-7302 —
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blo, p lion; vytthout o ary slpned walvor from the subJecf of fho rc a .. iny
1) Wn[o, par Codo efrom.94 atgmnal hktory recortot
In u waiver sl nefore from the ruh q Iola crltnlnaf hfatory record Information, ag allowed by jaw, a ays
J of of . he re uest.
/Yatver Release;1 herebyire
iu rordp!nna al Pertnitslco ror the above rcquatgn➢oRlcld to eordoot an (own arfminel his record aheo fth the Dlvipoa ofGimin0l
MYorltnlnol hletory dela canoe me me that tem Intafaedb
j IheDClnuyboralaasedAtallow, by
walver Slgnapteret
,�ryA L-r2m1na1 H stor2ecard
Check Re Its
As of =f UA* only)
a search of the provided name and date of birth revoglod;
Na lows Criminal History ROcOrd found with I)CI
❑ ao
Iowa Criminal History Record tittaehod, DCI ff
DCI inidals-� `
DCI -77 (08/25/10)
Received Time Apr,l1. 2016 6�59AM No, 2467