HomeMy WebLinkAbout16-1041 (Office Use Only)
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�` ( OWE CITY ryAPPLICATION FOR TAXICAB l MOTORIZED PEDICA#3 VEHICLE DRIVER
( Department review rrlust be made between E a.m. to 3 p.m., Mcnda r - Friday)
4I0 East Washington Street
Iowa City. Iowa 52240-1826 Failure to [Om iete £he "re aired" information will result in denial of the application
(319) 356-5040
(3 19) 356-5497 FAX
First Middle La t
1. Name (RFQUll ED) .__ �t'� ti
2. Addrass;RF{2U142EDj L _Jr(-���1si-
3. Contact Information? RFOUIRED! Email: 5ie�rra.CH(Leli Ue11Phone: -534,4004,3o
(All written communica Ids, sent via email) - '_--
r
4a. Chauffeur's License expiration date 'Rr QU;RED) -Q!t pp (�
b. Taxicab Business Name (REQ!j[RE G1) i ✓L g � _
5. Prior experience in transportation of passengers: [/j i7 V�k _
5. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?A)b
Type of offense Where-
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
Have you been arrested i charged with any traffic offenses in the last five years?
Tyne of offense Where
What happened to the charge? (Circle one)
Other
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
B. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense Where
When
City g'�
9. Have you ever applied to be an Iowa Cit taxi driver using a different name? If yes, please provide the names`
,
DEPARTMENT OF CR!'V INAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED w
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW ( i_`
You must apply for an individual Department of Criminal Investigation Report (form available upe5h requesi).
'_7
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
APPLICATION FOR TAXICAB VEHICLE DPAVER
;sage 2.
I hereby ceri,�tt` that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
144 A4' o Lo-7,;issued on 03/22/1to excirine on 4/18'/17 . I unders*and that if I
faiseiv answer any questions in this application, that this application may be denied. I agree that in making this appiication, 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, C aoter 2, of the City Code (Needs to be signed in front of a Notary Public)
Signature of
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this 3 day of
1 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 Gode). ,
Expiration datg of
or
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.
)2719ei r '_ I/ it' • `7C/.�1 if
SiggndKire of City Clerk or designee
Office Use Only
Approved application
DO! report n
State certified driving record _ ......
Website update
Iowa Department of Transportation
17 Ofte at Onlvef Sefvrees rTofi €=j BPIF "x3.2.1 tit
PO Bw 9204, nes Matnea,1A 563069204 51.',2444124
FNC 515-23941r37
IF4
Certified Abstract of Driving Record
Inquiry Date:
4/5/2016
DL/ID #:
144AC0675 (IA)
Customer #:
5262364
Name:
Caldwell, Sierra
Class:
D
ID Status:
None
Victoria
Address:
607 11TH ST
Audit #:
9875810
DL Status:
VAL
Issue Date:
03/22/2016
CDL Status:
None
City/State:
BELLE PLAINE, IA
Expiration Date:
04/18/2017
CDL Cert Status:
None
522081517
Endorsements:
3
CDL Med Status:
None
Mailing Address:
607 11TH ST
Restrictions:
Corrective Lenses
Restriction
None
Supplement:
Date of Birth:
4/18/1989
Mailing
BELLE PLAINE, IA
Sex:
F
City/State:
522081517
History
Information
CLEAR DRIVING RECORD
Name: Caldwell, Sierra Victoria DL/ID: 144AC0675
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 he set upon this document, at Ankeny, Iowa
this date:
IOWA
D. 0. T.
Name: Caldwell, Sierra Victoria DL/ID: 144AC0675
4/5/2016
:s
w
Office of Driver Services — --
Iowa Department of Transporation
c .n
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,Apr, 6. 2016,11:49AM oDly cf Criminal Investigation oq og 2O a ��;No.1228 ,gP. 1/7S ooa
STATE OF IOWA
Criminal Hijtory Re(Qrd Check
0 Requeo Foi-m'
luwa Viyision ofCriminal Invts(igaeion
Support Operallom Bureau, I`r Floor
2151;. Ira Street
Des Moines, Iowa 50319
(515) 725-6066
—(51'5) 725-60811au
W11 re uesiin an low¢ Cl
Last Name (mandnioq-)
Ca Id w a (
Date of Birth lmeodaio y}
04Ar'/r� �r l
Name
1)0 Accowu Number: 7 un
(r`rorun�nle}
Fronk: CiIVooflowaCltt�
City Clerk's --
!10 E. Waa Ull !un 5tree! --
-lo,Was'ityL1A_52240„
Phone: 319-356-5041
Fax: 319-356.5497
Qi'vlale Ell emale
_5 '7 ~ 47— r�e S 1
WaiVBriYlfO!•ffeq(i0tr: Wilhmd a signed waiver from the subject of We request, a contpiele criminal history record may rrol
he releasable, per Code of Chapter 692.2. For comalete criminal history record informalion, as ailoti�ed by law, altvays
obtain a waiver si nature fromroom the sublect of the reouect.
r release: I here 1lcrrnissionSnr.lbe-06 v
o a(equcsGngaffDial die r)CJr,,y bwn criminaiirlvUq•r�Gr7c�lc�r. ��i ilq the Lr— Il�rCrih incl
iml (IM). Any uintinal hismry dela eoneendag ntc that is maimflined by the TfC1 may be released as nllowcd by laq•,
n _
Waivet•S'igrtalure;.— 12�
1.)CI-77 (08/25/10)
Received Time Apr, 5, 2016 1:30PM No.1136
�,
ldebtrseonll)
As of a search of the provided name and date of birth
revealed:
No lotvrim
a Cinal History R,eoord found with DCl
....
1.
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L r
❑ Yowa Crimin) l History Record attached, DCI #
_'-
DU initials. .
�n
1.)CI-77 (08/25/10)
Received Time Apr, 5, 2016 1:30PM No.1136