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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 5 22 40-1 82 6
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. f U-1 L4 I
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between S a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
1. Name (REQUIRED) First D c- Y, •t
2. Address (REQUIRED) 2 I L
3. Contact Information (REQUIRED) Email:
Middle
D (I ()
_%-,,NI.JI:�-Q V. eklIGp�i
written communication sent via email)
Cell Phone: 319 - 2 J- S --
4a. Driver's License expiration date (REQUIRED)/ 3 A % .3
b. Taxicab Business Name (REQUIRED) C r r C&/Lj ,)e t n
5. Prior experience in transportation of passengers: c*
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? -
Type of offense- -
lsewhereT eofoffense_ -------Whew___ When
.6 h ��
S \
c wr
What happened to the charge? (Circle one) e✓Ar (S u -ec, j�k l ( G t w n
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been,d /charged with any traffic offenses in the last five years? _ �ye S
T e�of�off,_en�n e� j� I Where
r X7 �--
When
What 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?
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 neme(s)
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 iequest).
. TI
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cert) that r �I have issued to me by the Iowa Department of Transportation a valid Driver's license number
15-1 99� �! 3 7 issued on - /_� expiring on f Z ^ f'Z j . 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 pro Title 5, ter 2, of the City Code. (Needs to be signed in front of
a Notary Public)
Signature of Applicant --O�C-�_ Date �V� cl(!6
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by S W on this a5 day of
is in and for the State of Iowa
•�-w�ex�=xx;=wr+��n:r+w,tf:x:r�=x:xx=:;r��«�����<xx�xa>r++s:�����++�xx�x:ax*+>xw���++.t�:�=xxxx+++:ex����++:rxx:r=�x=xxx:rrw,��t+�=:�.sxx+�x<x:r+w+�rt+aa.+xx�zx+
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).
Expiration date of Driver's license 1-2,11 12,�
V�) S)) --
Signature of Police Chief or designee
gel 2�1�-6
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.
?(�.
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Oate
1
1._
e in
Clerk) IDRIVRADGE PPL92014amelded.DOC 07/2016
Jul 27. 2016 2:46 PM Div of Criminal Investigation No. 9130 P, 1/2
07/22/2016 16:6.. leas " .—v /002
STATE',OF IOWA
Criminal history Reep,rd Check
Request Form
To: lova Division of Crtminol fuvestigailon
Support Operatlots Bureau, 1" Floor
215 L 7'' Street
DUMoiues,lutva 50319
(5l S) 725.6066
(5l3) 725.6090 Fax
Slp�estill an Iowa Criminal I3istol ,Record Clfeelc on:
Last Marine (mandalory) First Namc (,nand;
�J
tol
DCI Account Ngmber;
(if alrylieahlCl
From: CifV Of 1'"'o City
City gier{iss Office
41Dfi. Washiueton tytrcet
_ Iarva City, TA 52240_
Phone: 319-356-5041
Fax: 319-356-5497
L')o".'eJs—
} 2- l + q (?- L - ��eus sa svum oer (rewirmmndel
_ ! j
male ElFemale
Waiver Xnf0rn1476011: Wilhdut s signed waiver ft•onE the subject of the request, a complete criminal hislory record may not
be releasable, per Code of Rowe, Chapter 692,2. For cep. 101ete criminal history 1'ecord information, as allowed by low, always
obtain a waiver sf nafure from thesubject of the request.
l alver Release: thcrebygivc permission f le above eslillofficial to uc
g Iowa critai0al history ruord chECk \vitlt lilt Division ofCrintinfll
Invesii�lien (DCI), ply criminal hivorydela con ming me That is ainlaincd by a DCI m y be renamed as allowed by law.
Waiver Signature:
lova Cr5CriffliDal
7WA01Y
Record Check Results
(DCl use duly)
As of tine provided name and date of birth nvealed-No lott�a tecofd ,found with BL'I
❑ rove Ci•ilninal History Record attached, ljCl!! -
DCI initials
—
DCI -77 (09/25/10)
S1
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Received Time Ju1.22, 2016 4:42PM No.0111
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