HomeMy WebLinkAbout16-1191 r �
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. 1�0-1_
(OfficeseU 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
First Middle Last
1. Name (REQUIRED) 'Sc
2. Address (REQUIRED) (rL ,S e z4�-:7 f Q r/a f / a ,I Ct 1A ` 2 f(D
3. Contact Information (REQUIRED) Email: (�2, e -(p(? 6P A kLb 0 �4g/J�, Cell Phone: ail?
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 0 F2 — l S -
b. Taxicab Business Name (REQUIRED) Ye (-I t_v C r,, 'b ,
c
5. Prior experience in transportation of passengers: o "I g, o G� C_
S' e u e
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? V c S
Type of offense Where When
Los A.jceele-c (cI ! 9 8 S
R
c argtr(Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense ,
S p�
Where
6--u t, Lt
2 n o s
Other
When
0r-03- 21013
OJ --2?—
What happened to the charge? (Circle one)
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? ^
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 th'name(s)_..'
41O r -j
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED ) M_t
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
1 hereby certify that I have issued to me by the Iowa Departmen of Transportation a valid Chauffeur's license number
�_(�� �,3 issued on expiring on /S I understand that if I
falsely answer any questions in this application, that this appl cati may be denied. I agr a thal 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
furtheragree th
documents relating to this application, and if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title .5;-C, mal 2, of ti, Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant E `� _ Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ti oUjc e, 'Wic' OCL�L(e_, on this 2day of
gaits - KELLIE K TUTTLE �-��'�!�
°L Cnmmresinn Number 227879 otary Public in and forthe 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, Ci Code).
Expiration date of Chauffeur' se
nature of Polte Chief or designee Date
AFTERAPPROVAL 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
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
Qi rr✓raxmr;ivenDGe Fr92014eme�ded,DOC 03/2015
901U"DOT
SMARTER I SIMPLER I CUST"OMcp DRIVEq Y°Bw'N iC3Vttradi' tgov
Inquiry Date: 6/7/2016
Customer #: 6027518
Name: Rivas Valle, Jorge Aid,
Office of Driver Services
PO BOX 8204 i Des. Moines., IA 50308-9-104
Phone- 5351-244-9 18GO-532-1121 I Fax: 515-239-1837
www-icwadot:gcy
Certified Abstract of Driving Record
ll #: 638AH7593 (IA)
Class: D
Audit #: 8876423
Address: 4494 TAFT AVE SE LOT 19C Issue Date: 02/26/2015
Expiration Date: 08/15/2017
City/State:
IOWA CITY, IA 522408166
Endorsements:
Mailing
Address:
4494 TAFT AVE SE LOT 19C
3
Restrictions; Corrective Lenses
Mailing
IOWA CITY, IA 522408166
Restriction None
Supplement:
City/State:
Restrictions:
Date of Birth:
8/15/1952
DL Status:
Sex:
M
None
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date;
CDL Permit
None
Expiration Date:
,�i6ieo..tl y
CDL Permit
None
Endorsements:
Iowa Department of Transportation
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status:
None
CDL Med Status;
None
conviction Date
01/03/2013 04County SUR ACD Expianatian /03/2013
02/22/2014 04/29/2014 M14 Fall to Obey Traffic Sign/Slgnal
592 .Speed -- 'Johnson 1A
,Johnson -.IA....
Name: Rivas Valle, Jorge Aldo Dil 638AH7593
the Pursuant to Ioof the wa Codeecords §321.lo, I, Melissa Spiegei, Director of Office of Driver Servicesue , Iowa Department of Transportation, do hereby certify that I am
said
office, that Irhave b enl authorized by the ffby the Director ice of Driver orf the Iowavices t of Transportation t Departmethis is a nto so certify,
copy of an official record currently in the custody of
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: Rivas Valle, Jorge Aldo DL/ID: 638AH7593
Oy
W89
IOWA `o
66/7/%2016
°
D. 0. T.
,�i6ieo..tl y
Office of Driver Services
Iowa Department of Transportation
06i1!un. 17. 20162 2:38PMCab Div Of (,r lmina1 Investigation (FAk)3193382:No. 6601 P, ,1/1/002
`�,Ii C1:VUlpSTATE OF IOWA'
;A"F tjj 1:43 fCriminal Record
Request Form
�t (U.IIypi 41��s'
To; Lown tltvlslon o(Crlmhsal lnvestigotlon
Support Operations 9uranu, 1" Floor
2155;, 7th Strect
Dcs Molnes, Iowa 50319
(51S) 725-6066
(515)'725.6080 Fax
DCI Account Number: 19967—F
llrspollcnble)
From) Yellow Cnb of Iowa City
P.O. Box 428
Iowa City, IA. 52244
(319) 3389777
Phonal
Fax: (319)339.7302
,.,wa• ,.x„ae Ima00tIG if'Irst Name mandoo Middle N tao recommended
C, Cc- n
l —5 S� L i msla ❑Fomale S� — �q — ! (� I I
Waiver Information: without a signed waiver rrom the aubJoct of the request, a complete criminal history r000rd play not
ba rotaosoble, per Codo of Iowa, Chapter 692.2, For comblete criminal hlstoryrecord Infarmetlon, as allowed by tow, always
(1618111 a waiver sionature from ihn snkf.ni nr fh,.-e,.......
Walver i4e/ease; I htraby give permisslon for the lbov vestfng orriciarlo ondum an Iowa f h rysocorQ ohetk with the pivlslon of Cominel
Invwdgatfoa (DCO. My criminal Matory dela coaccmin that h malntn d by a DCI nl released wtd by law,
WalveP Signature; f
As of fo a search of the provided name and date of birth revealed:
( No Iowa Criminal History R000rd found wide 17CI
El Iowa Criminal History Record atteehed, DCT
DC1 initials
DCT -77 (08/25/10)
Received Time Jun. 15. 2016 2:29PM No -7648
C