HomeMy WebLinkAbout16-229IDENTIFICATION NO. % 11P
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) 3S6-SO40
(319) 3S6-5497 FAX
lrst Middle
1. Name (REQUIRED) . Ol: L - br y
2. Address (REQUIRED)X3 C �✓e % 5%.
3. Contact Information (REQUIRED) Email: Y4fU-N"1AftCL96yA1L- .C'0M Cell Phone: J8 -5:y% os;3
(All written comm/j�nication sent via email)
4a. Driver's License expiration date (REQUIRED) 7/31/ a�`)1C6
b. Taxicab Business Name (REQUIRED) I fL0W 6U3 7y l�(� Cr7)e
5. Prior experience in transportation of passengers:
/V YePA5
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
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? lU
T
Type of offense Where 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? N C)
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 name(s)
A1O
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 herebyy�certify that 1 have issued to me by the Iowa D pa ment of Transportati n valid Driver's license number
43SZ� �O�S issued on MIT
expiring on 7 31 I understand that'rf 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 provision #Mlle 5, apter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by vni 6 S1� (ia 1 2 �. 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 071,.x, 12L) 1 g
Sign ure of'Policb 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.
4a lio ., i 'p, �i�.
Tignalwge of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
e
CIer TAXIDRIVB DGEAPPL92014amended.DOC 07/2016
0c t. I1. 2016 9 : 5 5 A M Div of Criminal Investigation No. 4980 P. 1/1
(FAx)3193382705 Y. uue/002
10/07/2016 09151Vellow Cab of 10W5 City
,r
STATE OF IOWA
Criminal History Record Check .
•. Request Porm ,
a
DCI Aocount Number.. 9967—)
��(ffappllcnble)
Tot Iowa Division of Criminallnvestisation Irromr Yellow Cab oflown City
Support Operations Bureau, V Floor P.O. Box d2s
215 B. 714 Street
Des Moines, Iowa 50319�owa City, IA. 52244
(525) 725.6066
(515)725.6080 Fax 1319) 338-9777
Phonot I
Fax, (29) 339.7302
I am requesting an Iowa Criminal Histo Record Check on:
Y.aet Nama (mandato First Name mandato Middle:N trle'(roeommandad
Date of Birth (mutdalo Gendermandato iSocial-Securl Number moommende
Male [IFetnale
Waiver leormation: Wlthollba signed waiver from thosobioct of the regpeat, A bornplate criminal history record may no
be relenlable, per Code of 16wo, Chapter 692.2.1rorCgriple criminal history reeor(1 Information, ea allowed by law, alWoya'
obtain a waiver sl natfire from the subject of the rt uesl. I n -
' I
WaNer Release; I haroby sive aemtbrlon for the %boys rckviliins ofaalal to cohduot an Iowa driminel hirtory record check with the Dlvnlon ON Minal
Inveaugmton (DCO, Any criminal history dais oonoemi % th.At Israel d by tho DCI may bo wleudd aalalloweti by law,
Waiver slpbrfureJ'L
I
T...ra 0"ivnSnal Viatnry<R arnrd' Check IZ.esulft (DC(via only)
As of l0- -I jo , a search of the provlded name and date of birth reveeled;
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record attached, DC1 # a
DCI -77 (08/15/10)
Iowa Department of Transportation
0 Office of Dover Services (Tal Free) 800 532-1121
PO Box 9204, Des Manes, IA 5030&9204 5155-244-9124
FAX: 5152391837
Certified Abstract of Driving Record
Inquiry Date:
10/5/2016
DL/ID #:
435ZZ1025(IA)
Customer #:
2308987
Name:
Bradley, Roger Elliot Class:
D
ID Status:
None
Address:
2327 E COURT ST
Audit #:
7383317
DL Status:
VAL
Issue Date:
09/27/2013
CDL Status:
None
City/State:
IOWA CIN, IA
Expiration Date:
07/31/2018
CDL Cert Status:
None
522455218
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2327 E COURT ST
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
7/31/1965
Mailing
IOWA CIN, IA
Sex:
M
City/State:
522455218
History Information
CLEAR DRIVING RECORD
Name: Bradley, Roger Elliot DL/ID: 435ZZ1025
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:
s•+[�11;(f`hyl
10/5/2016
D. 0. T.
411 ``••' s
1
Office of Driver Services
Iowa Department of Transporation
Name: Bradley, Roger Elliot DL/ID: 435ZZ1025