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Home My WebLink About16-171� r 1 -4 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) - IDENTIFICATION NO. (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 Middle L11Yet°- 2. Address (REQUIRED) Ar v/ 3. Contact Information (REQUIRED) Email: Ojor1 (Sb To� Cell Phone: (All written communication sent via email) 4a. Driver's License expiration date (REQL b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? !'t/ 0 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 91 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended (P16ad Guilty Other /IJ 0 Has your driver's license or chauffeur's license been suspended or revoked in t\\Fie 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 ft name(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE C"EFMFIEDf �. DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEFiiEVIqwl You must apply for an individual Department of Criminal Investigation Report (form avaitableppon rkwitist). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) I-7 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 hereby cert that I have issued to me by the Iowa aepartment of Transpo tion a valid Driver's license number issued on 1 �1-&expiring on s=/I understand that if I `Talsely 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 provision of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant � Date fNf Nf»ffffHf»ffffHff NH»HNf-ffiNiHN»fff»fff»ff»f»fef ff»»»HHfHf»ffff f»»»fff»»f»f f f fff»ff»H»»fff»f»ffff»sm STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me byTPs'eZa on this Zoi day of 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). license Pte( or - Z 5—/ 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. )n241e,V*W_) k . kZ44,1- Signaftire of City Clerk or designee 8-;L9-/ Date N O fiNtNffffffliflfiNMHH»ffHNfff11ff1fHfif'fHHN111f11ff1ff»Nf»}»»lfllfflff41NH1ff NfffHHff f Office Use Only j c- Approved application DCI report „ f! State certified driving record Website update o CAS RAXIMNBFOGEAPP M14.m dWDOC 07/2016 oei•Aug. 12. 2016>.B 9:39AMBab,Div of Criminal Investigation (Fax)3193m-ANo.1535 P. 1/1002 STATE OF IOWA . Criminal History Record Check is 1 Request Form To: Iowa Division of Criminal Investigation Support Operations Bureau, 1" Floor 215 E. 7'4 Street Des Moines, Iowa 50319 (515)725.6066 (515)726.6080 Fax I am reoucatina an Iowa Criminal Hlstory Record Cheak one DCI Aocount Number: ,_9967-P (If appileable) From: Yellow Cab of Iowa City P.O. Box 428 Iowa City, I.A. $2244 (319) 538-9777 Phone: Fax: (319)339-7302 tt Name (mandeary) First Name (mandatory)'--' Middle Name r000mmaod4d \o- ri2 Date of Birth (menduory) Gfendor mandato 'Sadal.Seeurl Number recommended D�--o\-- '� --GC) �Y�� OMale Sir mlae Walverinformadonr Without a aignod waiver from the subject of the request, a complete erlminal history record may not be ralessable, per Code of Iowa, Chapter 692.2. For comblata erlmioa) hlstoryrecoro Information, as allowed by law, always obtain a waiver al nature front the subject of the request, Waiver Release; I horcby &I" "rmlelen rot @a a¢yve reeoesting aflelal to Conduct m Iowa orlm(nal hlnory record eheok with We Divisten 001ndnal Invmlaadon (oc0. My edmlasl bluely date coca i 6fihe that Ir mdmalned by me DBI may bo mloued as allowed by law. Waiver Signature; (DCI'me only) As of —1 Z —1 . a search of the provided name and date of birth reve*84E rretnn .. - No Iowa Criminal History Record found with DCI --- c ❑ lows Criminal History Record attached, DCI # (� DCT initials DCI.77 (06/25/10) Received Time Aug. 10. 2016 3:33PM No.0255 CIowa Department of Transportation AO Of e of Drrver Services (Toil Free) 800-532 1121 PD Box 9204, DBS 141dn0S, IA 503069204 515-244-9124 FAIL 515-2391837 Convictions Name: Richardson, Teresa Lynette DL/ID: 537AG7824 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 N this date: o m C `+�iddt(f 8/10/2016 IOVV D. 0. : �i wnv� Office of Driver Services '^�Y� Iowa Department of Transporation Certified Abstract of Driving Record Inquiry Date: 8/10/2016 DL/ID #: 537AG7824 (IA) Customer #: 5855852 Name: Richardson, Teresa Class: C ID Status: VAL Lynette Address: 1312 SANDUSKY DR Audit #: 1213046 DL Status: VAL Issue Date: 08/09/2016 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 08/01/2021 CDL Cert Status: None 522405828 Endorsements: NONE CDL Med Status: None Mailing Address: 1312 SANDUSKY DR Restrictions: NONE Restriction None Supplement: Date of Birth: 8/1/1972 Mailing IOWA CITY, IA Sex: F City/State: 522405828 History Information Convictions Name: Richardson, Teresa Lynette DL/ID: 537AG7824 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 N this date: o m C `+�iddt(f 8/10/2016 IOVV D. 0. : �i wnv� Office of Driver Services '^�Y� Iowa Department of Transporation Name: Richardson, Teresa Lynette DL/ID: 537AG7824 N O_ CJ m O