HomeMy WebLinkAbout16-207IDENTIFICATION NO. I (
l 1 (Office Use Only)
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) 356-5040
(3 19) 356-5497 FAX
first Midd a Last 1
1. Name (REQUIRED) L— \�
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email:& y L�) Y\�j Cell Phone:
(All written commbnica..tion se 1a email)
4a. Driver's License expiration date (REQUIRED) 3 2 A t 2-h
b. Taxicab Business Name (REQUIRED) GC�
5. Prior experience in transportation of passengers: o
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State of9lsewhere?. N
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? N b
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other D
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? IN
Tvoe of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a dif(ecent name? If yes, please provide the name(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 request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
1`
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 yalid Driver's license number
fl b Q� 5 (Qcj issued on 5 r expiring on 3 r `[ r a' -U . 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 besigned in front of a Notary Public)
e
Signature of Applicant Date L t
STATE OF IOWA )
COUNTY OF JOHNSON )
bscribed and sworn to before me by k� ('e r) Ca r r-0 ( on this I � day of
2 ILP b�,
Public in and
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 J! C /?,-2d /
Date
(---b a ---
Signature of Police Chief or designee
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.
Sign re of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
9//9�/,-
Date
�a
0
v�
3
M'
—,
3
Clerk/TAXIDRIVBADGEAPPL92014am nde .DOC 07/2016
c
FeSep_�13, 2016 4:22PMG1orDiv of Criminal Investigation
N
00/07/2016 10:4 No. 2863 P. 1/3, ,see. . —2/002
STATIE OF IOWA
r,, CrrlmiflA IIIIiistolry Recgd Check ;' Request Yorm'
To; facia Division of Criminal Investlgaelon
Support operations Bureau, I" Floor
215 F, 7" Street
Des Moines, Town 50319
(515) 725-6066
(515)725-6080 Fax
I am reauestine an Iowa Criminal History Record Check on:
J)CI Account Number; L --J fzt-) -r—
(if pplinb1t)
r—(ifnpplinbla)
From; City of Iowa City
City ClerICs Office
40 r. Washington Street
Iowa City, 1rs 32240
Phone; 319-356.5041
Fax; 319-3515497
Just Name (mandatory)
• First Name (nlandalofy)
Middle Naglee((recommended)
Date of Birth (mandalo 9
Gender (n,endarory)
Social Security Number (recommended)
-�r tA t I �
❑male LYTetnale
3(b lQ bO oC9 a41\
Waivel• Infal-matfart: Without a signed waiver from the subject of the request, a complete criminal history record tray not'
be releasable, per Code of Iown, Chapter 692.2. For complete eriminal history record Information, as allowed by law, always
obtain a waiver signature from the subject of the request.
Waiver Release: i hereby give permission for the above requesting official to conduct on Iowa criminal hismry retard check with the Division of Criminal
lnvulipdan (DO). Any criminal history data concerning nm Ilial is mainsained by ilia DCI may be released as allowed by Imv.
Waiver Signatur •
Iowa Criminal History Record Check Results _ (DClus. only)
As of l�U , a search of the provided name and date of birth ret+ealed:
u=
No Iowa Criminal History Record found with DCT b ` f: i
I
Iowa Criminal History Record attached, DC1 k
DCT initials I,% N
I]CI-77 (08125/10)
Received Time Sep. 7. 2016 10;300 No, 3442
11
Iowa Department of Transportation
AW Wce of Omer Services (Toll Free) OOD-532.1121
PO Box r3204, [les Moines, IA 503060241 515-2449924
FAX: 515-239-1837
CLEAR DRIVING RECORD
Name: Carroll, Karen Lynn DL/ID: 06OCC9569
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:
9/19/2016
a�f
D. fl. T.lf
Office of Driver Services
Iowa Department of Transporation
Name: Carroll, Karen Lynn DL/ID: 060CC9569
Certified Abstract of Driving Record
Inquiry Date:
9/19/2016
DL/ID #:
060009569 (IA)
Customer #:
4499601
Name:
Carroll, Karen Lynn
Class:
D
ID Status:
EXP
Address:
2429 WHISPERING
Audit #:
9342492
DL Status:
VAL
MEADOW DR
Issue Date:
08/15/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
03/04/2020
CDL Cert Status:
None
522406807
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2429 WHISPERING
Restrictions:
NONE
Restriction
None
MEADOW DR
Supplement:
Date of Birth:
3/4/1978
Mailing
IOWA CITY, IA
Sex:
F
City/State:
522406807
History Information
CLEAR DRIVING RECORD
Name: Carroll, Karen Lynn DL/ID: 06OCC9569
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:
9/19/2016
a�f
D. fl. T.lf
Office of Driver Services
Iowa Department of Transporation
Name: Carroll, Karen Lynn DL/ID: 060CC9569