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Home My WebLink About16-098CITY OF IOWA CITY 410 East Washington Strcct Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. — 14- (3 67 x (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 Last 2. Address (REQUIRED) /2,20' /4 S art o f 3. Contact Information (REQUIRED) Email:ecA, rle. ,'c OM54 r CellPhone:3/9 3as-5ylo (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) 4,4 r, / 30 P-0,2 b. Taxicab Business Name (REQUIRED) _ 5. Prior experience in transportation of passengers: /5- e rs ;, 14.reK 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) A 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) 02/2015 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty - 7. Have you been arrested / charged with any traffic offenses in the last five years? �O'tther t r ( Type of offense Where When t' What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other �1 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ v V n 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) A 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) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Dep rtme t of Transportation a olid Chauffeur's license number C%c1 In/t^/ � $3 6 issued on � a3 or expiring on a`/ 30 ;2v vl understand that if I falsely answer any questions in this application, that this applica ion may be denied. I agree 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date Z7 / 3 0�6 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by )� J; L, ��26Or_ on this ._« day of �Aj. —� Public in ander the State of 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 Chauff s license Ou v 2 Z� Signature of P lice Chief or d nee Z0( 6 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 Office Use Only Approved application DCI report State certified driving record Website update ate r— Clerk/TAXIDRIVRADGEAPPL92014amended.Doc 03/2015 WADOT gov Office of Driver Services P0 Eoa. 9-2104 Des FAVIreS, 1,4, 50306-921:4 ,15- 44-9124 j 80G -5s2 -"2l ; 1•.7x.- W IS -.233-183,7 wire.iaivadot.gov Inquiry 5/13/2016 Date: Customer 4138394 Name: Bergen, Christopher Charles Address: 1920 H ST City/State: IOWA CITY, IA 522402029 Mailing 1920 H ST Address: Mailing IOWA CITY, IA City/State: 522402029 Date of 4/30/1965 Birth: Sex: M Certified Abstract of Driving Record DL/ID A: 005WW9836 (IA) CDL Permit Class: None Class: D Audit #: 8006344 Issue Date: 04/23/2014 Expiration 04/30/2020 Date: Endorsements: 3L CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit None Restrictions: EEG ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: 7F RRIViR S Office of Driver Services CDL Permit EEG Status: CDL Cert Status: None CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Bergen, Christopher Charles DL/ID: 005WW9836 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: Name: Bergan, Christopher Charles DL/ID: 005WW9836 5/13/2016 IOWA 7F RRIViR S Office of Driver Services Iowa Department of Transportation Name: Bergan, Christopher Charles DL/ID: 005WW9836 90ay. 3. 20161: 3 : 2 3 P M D l v of Criminal 1ovaati,ation U + DCI IO345? N o. STATE OF IOWA Criminal History Record Check "+ Request Form To; Iowa Division of Criminal 1pvestlgatlos Support Operations Bureau, 10 Floor 216 L 74 Stmt Des Holosa, Iowa M19 (516) 7254066 (515) 7256080 Fac I um rcauestine an Iowa Criminal History Record Check on.' DCI Account Number: H383 - FC, From: Amos -FOL (Ile 5i-tvt-i Lir. Phone: (314 35F - vex— 319 351 Last Name Flrrstt Name rnedda Mlddle Name roto !✓eij� W1 % L/Oi✓tV- C— 11, 4 r /ds Date dllkrfh raamuo Gender mo4o Social Security Number r 3 G p65 Ip CiFemale `l7S' 6'7' Y IYalveriAr0rffxN10A: Without a aligned walver holo the subject of the request, s complete crlml0al history record may pot bs reitasabie, per Code of Iowa, Chapter 6922. For golaOjpjp criminal history record Information, as allowed bylaw, always obtain a wntver al ature from the subject of fhor nest. Walver Release: i haaby give per Nnim for me olTicw w carAWI on Iowa %6mltul himy rwotd check wah the DbLlm of Comllwt Investigation (DCI)- Auy taVekjW htawy dens wnownfnd me that 4 melnWrm by rhe DCl may he mLca w w eanvved by law, Walver Skmafare. (DCI she otdy) As of J a search of the provided name and date of birth revealed: No Iowa Crlminai History Record found with DCI ❑ Iowa Criminal History Ro=d attached, DCI # DCI initialsr- DCX-17 (08/25110) Received Time May. 2. 2016 10�06AM No. 3548