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HomeMy WebLinkAbout16-103IDENTIFICATION NO. _.) ( f--) () 3 (Office Use Only) APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA C ITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) 410 East Washington Street 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 First Middleast 1. Name (REQUIRED) �3 ^ SArruEr— j�ife y )g 2. Address (REQUIRED) �/ S '7-fk AvE /OL.J4 crTV lit sQzyo 3. Contact Information (REQUIRED) Email: qe scnstsei.2 �4M4'/ co. Cell Phone: 3(i-YV/-q/,45 `(All written communi ation sent via email) 4a. Chauffeur's License expiration date (REQUIRED) oZ /1 Id. Taxicab Business Name (REQUIRED) T4oq 5. Prior experience in transportation of passengers: I\Jr vc + Y6,1KS As' 4 —(;Wf pK 1V;5ti 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /-b Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When 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? 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,riame(s) NG DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE :CERTIPIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available uporti. (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 111 02/2015 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 43V Zz oS 7r issued on OZIZ3/13 expiring on o.zlr2/iS . 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_, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date ✓`��' �S- STATE OF IOWA ) COUNTY OF JOHNSON ) 1r Subscribed and sworn to before me by 'Tr, rr`2 S -Sn on this Q4�— day of Lq 1 1 t_1 roti � 5 i"Lq� 8 . and for the $¢ate 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). is license 2% I L I or designee �l h/ll 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. Signat of City Clerk or designee he, " Date Office Use Only Approved application DCI report - State certified driving record Website update cn cien<r MURivanocraPPL92014amended.00c 0312015 o5Aay. 3. 2016.3 3 23PM Div of Cr minas lnv=stigatlon , DCI Io)No.3413 STATE OF IOWA Criminal History Record Check Request Form Ta: laws Division of Criminal lavwligaBoa Support operatlooa Bureau, IN Floor 215 L 70 street Des Molnes, Iowa 50319 (513) 7;"M (515) 715.6010 Fat 1 am arnunnno an rnwa Criminal Hlstmv llmrtr l M: .le nn - D CI Account Number. 3g ^�}�(IfapplW e) .. From, AVS r AXI _ Phoaor .(3(R 33P- Faa; Last Name (MWW. First Name n. d Middle Name,ow Pa915�3 --74A� bete of Birth oallaslo I Ge derSocial Security Number r d'Z ( lZ�l �� �A1nle ©Fems[e JrdS 13 —D29 Waiver Injbrnmflow without a sigma wolvar from the subject of the request, a complete crtmlbal history record may bar be releasable, per Code of lows, Chapter 6922, For gnlWW criminal history record Information, so allowed by law, always obtain a watygr d olure from the subject ofthe rocuest. Waiver xelease1 haebyelve ymlulon for d,e above mgso mPz offtW to ann&wr m lows criminal hbsoy rocord chat win, a,e nlvbran of Wmlasl Invpallrodva(DCl). Any mrunv hlao(y4moD me1ha111 malnlalaA by Ws mrybo mlooduallownd by low. Waiver Slgnafwne: Iowa Criminal History Record Check Results .. (JC�iw easy) As of 5J- a search of the provided name. and date of birth reycaled: < _ I No Iowa Criminal kllstoty Record found with DC1 c_' ❑ Iowa Criminal History Record attached, DCT # DCI initials - ICI -77 (0825110) ca zx- Received Time May. 2, 2016 10:06AM No. 3546 Cmmiciviiadotgov �f= A R f LR I vfMPLI. 1 i Cf '�� TOM`u D R I gi FN Inquiry Date: Customer Name: 5/19/2016 4732685 Office of Driver Services PC: Box 9204 1 Des Moines, !'A 50306-92C,4 Pho,°,e: 595-244-9124 1 8:06-532-1121 ( Fax 515-2"31337 www .io ao:lot.gov Certified Abstract of Driving Record DL/ID #: 434ZZ0578 (]A) CDL Permit Class: None Class: D Parsons, James Samuel Audit #: 6719710 Address: 801 5 7TH AVE City/State: IOWA CIN, IA Issue Date: 02/23/2013 Expiration 02/12/2018 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Parsons, James Samuel DL/ID: 434ZZ0578 CDL Permit Issue None Date: CDL Permit 522406205 Mailing 801 5 7TH AVE Address: None Mailing IOWA CITY, IA City/State: 522406205 Date of 2/12/1981 Birth: None Sex: M Issue Date: 02/23/2013 Expiration 02/12/2018 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Parsons, James Samuel DL/ID: 434ZZ0578 CDL Permit Issue None Date: CDL Permit None Expiration Date: None CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: None COL Permit ELG Status: CDL Cert Status: None COL Med Status: None 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: IOWA D. 0.T Name: Parsons, James Samuel DL/ID: 434ZZ0578 c, 5/19/2016 -, Office of Driver Services Iowa Department of Transportation _ a CJi