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HomeMy WebLinkAbout16-189I r I 0- �®64 ra.rt4_ CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. (Office Me 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: MR5hjj0lf f t?j2__ ibVAAk)V ell Phone: (All written communication senl via email) 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) /lio411-�.1/l-' LA 1 i 5. Prior experience in transportation of passengers: . A 01 -Tv VcLzxa 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense What happened to the charge? (Circle one) Where When 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 S' /zlc What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty OtherN- 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five y Type of offense /� / ) Where When -MV p_. A/ ✓ '—� N 1 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide &EI 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 De a ent of Transportati n a valid Driver's license number a Cj97 issued on ex irin on y I understand that if I '% ` P 9 falsely answer any questions in this application, that this ap icat n may be denied. agr 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, ChgMer 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date Z 12 0� b STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by C- .cjpfp'ro �_ Si ck�ej-r0 ►J on this Z day of t�M..J.n� l9 1 1ti n 1 .04 S. in ald for the 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 q/2 -//J - Signature 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. 'Sig ature of City Clerk or designee v 0 r- Office Use Only T -C 1 Approved application rT1 DCI report �}-a State certified driving record _ '" r Website update o In Clerk MIMIVMDGE PPL9201"mended DOC 07/2016 ..i: 0 0 T SMARTER 151MPLER I CUSTOMER DRIVEN VVWW.Ii]VVadot gov Office of Driver Services PO Box 9204 1 Des Moines. LA 50306-9204 Phone: 51E-244-91241 BOD -532-1121 1 Fax: 515-239-1837 ` www.iowadol.gov Certified Abstract of Driving Record Inquiry 8/9/2016 DL/ID #: 700AI0627 (IA) CDL Permit Class; None Date: -09/05/2014--_—�_-- 592 ]Speed -------I3ohnson _— IIA Customer 6101512 Class: D CDL Permit Issue None #: Date: Name: Bickford, George Audit #: 7011629 CDL Permit None Frederick IV Expiration Date: Address: 401 9TH AVE Issue Date: 06/06/2013 CDL Permit None Endorsements: Expiration 01/15/2018 CDL Permit None Date: Restrictions: City/State: WELLMAN, IA Endorsements:3 ID Status: None 523569338 Mailing PO BOX 296 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing WELLMAN, IA Supplement: CDL Permit ELG City/State: 523560296 Status: Date of 1/15/1967 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County 3UR 11/23/2013 -09/05/2014--_—�_-- 592 ]Speed -------I3ohnson _— IIA Name: Bickford, George Frederick IV DL/ID: 700A30627 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 this date: P....... 8/9/2016 IOWA.. °y D. 0. T. e.�,s' fj�/ a�Rl� PiC f . sv>- f D..VEB�°—'— Office of Driver Services Iowa Department of Transportation Name: Bickford, George Frederick IV DL/ID: 700AJO627 „,Sep, I. 2016, 5:00PM,'div of Criminal Investigation oa/30�2016 ls;3No. 32326a,P:. 3/3,002 �a- STATE OTa IOWA Clruuon>iwal History Rete ,rrd] Check l c Request Forem' To; lows Division of Criminal Investigation Support Operations Bureau, PI Floor 215 E. 71n street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax `-2 9 z�O"�6 DCI AccoulIT Number: L(o oZ-F (lf applicobleJ From: City offotva City City Clerics Orrice 410 P. washingtan 5trcee Iowa City, fA 52240 Phone: 319.356.5041 pax; 319.356-5497 P(NYale ®Female I?— I z J %Z,• l'O 2 Wfftver-MfOrfrtnOM' Without a signed waiver from the subject of the request, s complete criminal history record may not be releasable, per Code oflowa, Chapter 692,2. Forco- mplete criminal history record information, as allowed by law, always obtain a w9aiW8Y sinna[ure irnm Ihn enhinnr nfYl.n ..e....e.. Wniver,Release: l hereby givepefmission for the abovc fequesling eir,I,l to conduce on Iowa nominal history record cheek,viW Ole Division of Criminal Investigation (DCI). Any criminal history dale concerning me at is maintained b the nCl me `be. released ns allowed by law. WaiverSiPnofure: M Ate- /. ji ”. _ A n I _. 7[ow a Ca iminal �istory ][taco rd Check Results DCI use only) As of �_ ��p a search of the provided name and date of birt7revea1pdT-:7-- No l0'lVa C1•iminal Histoly Record found with DCI IJP © Io•kla Criminal Ilistory Renard attached, DCT 2i DCI initials— 00 DC1,77 (08125110) Received Time Aug. 30. 2016 1:15PM No, 2922