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HomeMy WebLinkAbout16-137IDENTIFICATION NO. ILO — 13 –1 1 1 (Office Use Only) ^ ®4It APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (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-SO40 (3 19) 356-5497 FAX First Middle Last 1. Name (REQUIRED) 2. Address qq �T��- 7ar.�_ (REQUIRED) REQUIRED 3. Contact Information (REQUIRED) Email: Cell Phone S3 (All written communication s nt vim a email) 4a. Driver's License expiration date (REQUIRED),,pp,�? b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passeng rserse 'fit, O 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A4 Type of offense Where When What happened to the charge? (Circle one) 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 / ^� Where When q 6,t �a � .>.fi�t.r-.i ;,Tk '306•` �ly� 1.J- W hat happened to the charge? (Circle one) 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? 4 Type of offense ere ,_ d Whers � iV v [ � 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide tfie name(: C.0 — ..r 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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number XW 41 issued on Z7-_ / expiring ons Z,2g/,- . 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 2, of the City Code. (Needs to be signed in front of a Notary Public) i �1- Signature of Applicant STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by So ¢ a}b e^ on this 1 day of CLL4 o, , & 1 Z -O! In �- 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, Coity Code). Expiration date of v 's license �li 0 ignature of Police Chie or designee D to 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. igna ore of City Clerk or designee Date -rte xxNxxxxxxxxxxxxxxxxxxxx+++x+x+Wx##*#xx*xx+xxxxxxxxxxxxxxxxxxxxxx++xx*x#W###xxxx*xxx++xxxxxxxxxxxxxxxxxxxx+++#xW*Fx#-.Ftit�xxxxxx�xx�xx*xx*xx*x}x* Office Use Only _ Approved application DCI report } State certified driving record Website update Clerk/ IORIV ADGE PPL9214amended.00c 07/2016 (OwWA � DOT vuwwnf.iowadoixgov SMARTER t SIMPLER 1 CUSTOMER DRIVEN Office of Driver Services PO Sox 22041 Des Moines, IA 50306-9204 KW -515-244-9124 [9O0-532-1121 I Fax 515-739-M7 wAw3owadotgov Certified Abstract of Driving Record Inquiry Date: 7/29/2016 DL/ID #: 662YY1237 (IA) CDL Permit Class: None Customer #: 1895748 Class: D CDL Permit Issue None 'IA 11J26/2D33 :01106/2014 592 Date: Scott Name: Nguyen, Son Minh Audit #: 6BB4444 CDL Permit None _ IA Expiration Date: Address: 2557 INDIGO DR Issue Dote: 04/23/2013 CDL Permit None Endorsements: Expiration Date: 08/01/2016 CDL Permit None Restrictions: Lny/*tate'. I iNA I.I IT, W �zz4uw44 tmoorsements: S 1Y bwtus: None Mailing 2557 INDIGO DR Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status! None Mailing IOWA CITY, IA 522406824 Supplement: CDL permit Status: ELG City/State: Date of Birth: 8/1/1966 CDL Cert Status: None sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 01/30/2012 X02/20/2012 iS92 +S _ I peed - Johnson 'IA 11J26/2D33 :01106/2014 592 ',Speetl-_^ Scott IA 04/05/2014 _ p5/O6R014 _ X592 T __.__ inpeed (10 mpn & under m 35-55 mph zone) .__ Johnson _ IA Accidents - Accident involvement Indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 02/39{2012 1675679 IA Name: NgUyen, Son Minh DL/ID: 662YYI2.)I Pursuant to Iowa Code 9321.1D, 1, Melissa Spiegel, Director of Office of Driver Services, lam 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 mused my signature and the seal of the Department W be set upon this document, at Ankeny, forfa,jnLS date: m tt11Cll "•'••`� '-�:i t��•. ®t.D.O.T 712912016 .., �- •., Dwa ice of Driver ,...� 1 IoDeDepartmentnentat of Tra Transportation ,lu,.2�. 2016 3:181M Div c. GiigiIPaI Invesi,galiCn No. 8884 P. 3 Fr- , . -we -y Clark - --u--- 07/20/2016 13:00 IC66 1.,,02/002 STATE OF IOWA 1l '`aoP Criminal Hiqory Record Check Request Form To: rowa Ll of Criminal Investigaeinn support (Operations Durcau, 1" (;loos. 215 E. len 9treet Des Moines, Iowa 50319 (515)725-6066 (515)725.6090 Fax �. 1. 1Y. -,.• 1 1 aro reauestinp an Iowa Criminal Ilistoly Record Check on� DCIAccounI1\tumbet 14v0'�_—F— (ifnpplicnhle) —_ From: City orIowa Ci City Clerk's OfGue Al0 C. Washington street lawn C.'ity, IA 52240 Phone: 319-356-5041 Fay: 319-3565497 _Last Name (mandatory) First Name (mnndaloryf Middle Name (rew,lr„eaded) �Y-_ /vl Date of Bir h (mandalory) Gender (marl Social Seell IVurrlher (recommended) cl2i' .'®/f�� LTale �Temale f %1V 77© `-�'21 �J Will Inf0f H7nr7074: without a signed waiver Rom the subject of the request, a complete criminal hisfory record may not be releasable, per Code of Iowa, Chapter 692.2, pm, complete criminal histoq- record information, as allowed by late, alivays obtain a waiver signature from the subject of the request. YIRelver Release I hereby give sacmiissiou for the above rcquesling official la conduct an )ave criminal h(stop' record check wide the Division ofcrimiuol Investigation (PC). Any criminal history data concerning me that is malhtaim•-0 b Cl maybe releesed as allowed by law, Mal Signature: �-=�_ As Df � , a search of the provided name and dale of bitth revealed: jjj I. C' No Iowa Cl History Record fou)ad with DCI M Iowa Criminal History Reocu•d attached, DCI DCT initials--_ 17L'1-77 (osnsno)-- - J--� ----- Received Time Jul 20 2016 12:50PM No.9924 r SDCtuse only) r�> .. L e.;.:..1 r. 0 0