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HomeMy WebLinkAbout16-110r i ��G.ma7 � �IIIMtpF �� CITY OF 10"'A CITY 410 l=ast Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 (319) 3356-5497 FAX (Office Use only) APDL CATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVE+ ,Police Depariment review must be nnade between 8 a.m. to 3 p.m., Monday — Friday) Failure to corn Jere the 'required" infomra Lon will result in denial of the aPplicalion First 1. Name Middle Last e,k G 2. Address 2 \L , l—..__iJ r rte L:tScrr l� Sz31� _ -- 3. Contact Information tF r :t'i.11RF:E�j Email: C&, + n ntu' E' Cell Phone: Y( �6j 1 All written communication sent via email) ----T... 4a. Chauffeur's License expiration date b. Taxicab Business Nameli;,EQ tir;Et Prior experience in transportation of passen^ers: (asL'fr trahsa:rA-. —- 6. Have you ever been arrested/ charged with any misdemeanors andlor felonies in this State or elsewhere? h o Lyg of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested I charged with any traffic offenses in the last five years? Where .1 1 Ftrcd, What happened to the charge? (Circle one) When Convicted Dismissed Deferred SuspendedPlead Guil Other _ 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ___✓t ,� Type of offense Where VJhen 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the names) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATeCERTIF4IED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RE!(IEV'y You must apply for an individual Department of Criminal investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) APPLICA"i IOi3 FORTAXICAB VEHICLE DR"tVER Page 1 hereb certify that I have issued to me by the Iowa Department of Transportation a v lid Chauffeurs license number �� CC 3533 issued on 5 expiring on S I understand that if I falsely answer any questions in this application, that this aplikation may be denied. I age e 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 TW r, hapter 2, of t ty Code. (Needs to be signed in front of a Notary Public) Signature of Applican' _ Date- to / STATE OF IOWA ) COUNTYOF.IOHNSON ) Subscribed and swom to before me by r, : r0,^ C -I& K -L meson this -7 day of -Ti�-._.2 Zoll2 - _ I - in and for the Stafelof Iowa I have reviewed this application, DCI report, and the State certi led 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 S. (i q �!� 0 i� Signature of Police Chi f r - 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. tgn tune of City Clerk or designee Date X*YY*•*x**YX**X*%aa***F*ax#XX***s*+%**%**kk*aa*arXr*+.a#xa+:++:Xkewkx%aa.r*x%*aa*Xeaa£aa*-*xesxxa*#a'a#a**.*Xa*#axaka%aa*asa%a**i�;Nk%+a*+xX'**:X.zarm+k Office Use Only i _r Approved application -- DCl report State certified driving record Website update — " Iowa Department of Transportation C.+w1ffG4 Y1t %5 `,.`c�'�E'3 s1 13 me! %aU 5.32 1121 WC1 i3oal 5204 Ges Wig". t A 50306 X244 51h-244 4124 FKX 51111, <33 1 rV Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 5/25/2016 DL/ID #: 336CC3533 (IA) Customer #: 1721716 Name: Freeman, Cameron Class: C ID Status: None Oljans Address: 845 FAIRVIEW LN Audit #: 7860347 DL Status: VAL Issue Date: 03/07/2014 CDL Status: None City/State: NORTH LIBERTY, IA Expiration Date: 05/19/2019 CDL Cert Status: None 523179180 Endorsements: L CDL Med Status: None Mailing Address: 845 FAIRVIEW LN Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 5/19/1986 Mailing NORTH LIBERTY, IA Sex: M City/State: 523179180 History Information Convictions Citation Date Conviction Date ACD Ex lavation 01/25/2016 02/29/2016 592 Seed ]�Joh�ns�on �6� Name: Freeman, Cameron Oijans DL/ID: 336CC3533 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: 5/25/2016 IOWA `;'A'I Office of Driver Services Iowa Department of Transporation Name: Freeman, Cameron Oljans DL/ID: 336CC3533 dun. J, LU10 y:9)hlvl uiv 01 1, In]InaI 111vest19at10n ie -o, 7709 r. ve Fram:Cliy of Iowa City Cicrk Otrloa 310 3666497 05/27/2016'13:6.5 6Em2 r-vire/002 STATE OF rt -P Crimilial History Record Cheek Request Form To: lovia Division of Criminal Investigation Suppovi Operations Bureau, 1" Ploor 215 E. 7u' Street Des Moines, Iowa 50319 (515) 725.6066 (515)725-6oao Fas I nen reminoina an lnurs Cwinainal l4letm%, RecAcrl C6er4 A,, - IK f)Cl Aeoounl Number: 4coa - F --(irapplicable) From: Ctty of Iowa Ctt7I City Clerll's Office 410—EW ashington SSrcet Iowa City, 1A 52240 Phone: 319-386-5041 Fax: 319-356-5497 Last Name (mandatary) First Name (niaadalory Middle Name (recommended) 1 r-e—e v-- c, ✓i C NV --L V✓o `—I ©(J Gln S Date ofAirth mandaiory) Gender(niaadarory) Social Security Number (rrct9m»endrd) IL Amale ❑female Waiver Information: Without a signed waiver from the subTect of the request, a complete criminal history record may not he rcleasa6le, per Code of low.4, Chapter 692.2. ror complete criminal history record iuforntation, as allowed by law, always olltaiu a waiver sl nature from the sub act of the request. WaiVel' IteieaJ'e:: I hcrch7give pcnnisslan for the alMvp rogecsling offmial to conduce an fo+va criminal hillopretard theca will the Division of Criminal hwectigaliou (DCI). Any criminal history data conccming me chat is nlaimal the Dy('1Lm"6aleascd as allowed by lax'. — Waiversignaim'e: Io'c'fra Criminal Histo✓ Record Check Results (opt„sea,,,.) As of(6�3 �� �. , , a search of (he provided name and date of bi1111 rer(ealed: _ No Iowa Criminal History Record found with DCT -, ❑ Iowa Criminal History Record attached, DCT #'' ` z- 'K'I-- -, W t,.J T)CT itlitials.� - _ 1)C1-77 (08/25/10) Received Time Mav, 97. 9016 1: 11 PM No, 6394