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Home My WebLink About16-152a r -k CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 5 22 40-1 82 6 (3 19) 356-5040 (3 19) 3S6-5497 FAX 1. Name (REQUIRED) 2, Address (REQUIRED) IDENTIFICATION NO. 1I o) 5 Z (Office Use 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 3. Contact Information (REQUIRED) Email: (All written 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passrnge sent via email)v 2 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? _n Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? 1' I Other Convicted Dismissed Deferred SuspendedPlead Guilt 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 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 her erb-� ce `t�} t ave issued to me by the Iowa �tionmay Transportat n a valid river's license number / zq T 1 O issued ciring on I understand that if I falsely answer any questions in this application, that this a denied. agre 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 6, Chapter 2, of the City de. (Needs to be signed i front of a Notary Public) Signature of Applicant Date 8 3 1Z 0 STATE OF IOWA ) COUNTY OF JOHNSON Subscribed and sworn to before me by ) 1_ npui-A �� i r,} on this _ day of 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 ' k(?o l7 yv g1it r -6 tur Sign of Police Chief or 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. Signature of City Clerk or designee Date <7T, Office Use Only i*) Approved application DCI report' State certified driving record Website update Cie,VFMDRIVB DGEAPPL92014a1llded.DOG D712016 F,Aug. 5. 2016„4:24PM�,.,Div of Cciminal Invest igai;on oe,osi2o,e,,:No.9908gaP..1aoxrooz 1 STATE OF IOWA er) Criminal History Record Check RequesstTFGrm To: Iowa Dfvigion of Criminal Investigation &uppa-t 6Pe1:2ttnna Bureau, I” Floor 2151;. 71h Street Des Moines, Iowa 40329 (515) 925-6066 (515) 725-6080 Fax Nen-Fh Date of)3'rif, (mai ardry) .L9 Y9y Clr'st 1Vamc (uandriory) Tk C�rnas I DCI Account Nuinbcr: Yob'Z-f_`_ (if applicabie)� From_ City of Iowa City CityCleries CDffice---�'-...------ 410 F. Washington Street Iowa Clty, I&_522410 Phone: 319-356-5041 Fax: 319-3565497 -- Male ❑Female f=-c r -J 295.1 Warvef Xnjormafiorr: Without a signed waiver from the subject of the request, a enmPlete criminal history record may not be releasable, Per Code of lova, Chapter 6912, For Comnlcte criminal history record Information, as allowed by law, always obtafn a waivtr sipnaiure from the cu h6m �f thn Walver Releaser l hcraby give permission for Ne above to conden en love criminal hind surd eheck U-1111 the Division OfComioat Invesligalion(OCI). Any atminal history data crosoentingme that is mai�Clinoybe released asosve by re' WaiverSignaiure: Iowa Criminal History Record Check Results —� p)Ct use ent71 �� ({� a search of the lllovided dame and dale of birth Ievealed, As of No 1ovva Criminal History Record fomtd with j]Cj ;1M v J M.l CA, Iowa Criminal Hisfory Record attaciled, j)Cj # U DCIhiiiials__ _ ^1 CID DCI -77 (OS/25/10) Received Time Aug, 3, 2016 11:02AM No.0628 FA Ofte of Urfref -4efvli:en ++ PO Boa 9204, Om Marrs. bol 503Ui* 9204 Of' T: ansp nation {'loll Free) M 532112'1 51!Y -244-W4 124 i AX: 515 239 1837 Certified Abstract of Driving Record Inquiry Date: 8/3/2016 DL/ID #: 769YY6103(IA) Customer #: 915880 Name: Heath, Thomas Class. D ID status: None Edward Address: 2801 HIGHWAY 6 E Audit #: 6044993 DL Status: VAL LOT 394 Convictions Citation Date Conviction Date Issue Date: 06/13/2012 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 05/19/2017 CDL Cert Status: None 12/27/2015 522402658 M14 Fail to Obey Traffic 5i n/Signal Johnson IA Endorsements: 3 CDL Med Status: None Mailing Address: 2801 HIGHWAY 6 E Restrictions: NONE Restriction None LOT 394 Supplement: Date of Birth: 5/19/1959 Mailing IOWA CITY, IA Sex: M City/State: 522402658 History Information Convictions Citation Date Conviction Date ACD Ex lanation lCountv 648797 3UR 07/07/2013 07/18/2013 S92 S eed Linn IA 12/27/2015 01/27/2016 M14 Fail to Obey Traffic 5i n/Signal Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 09 19 2011 648797 IA Name: Heath, Thomas Edward DL/ID: 769YY6103 LL ,,- Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of �"ransportation, do s, hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accuraie;'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: