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HomeMy WebLinkAbout16-240r yltyl®i�� CITY OF IOWA CITY 410 East Washington SIrce( Iowa City. Iowa 52240-1826 Q 19) 356-5040 Q 19) 356-5497 FAX IDENTIFICATION NO. II to — A `i O (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 1. Name(REQUIRED) f{ i+lldyf J'-rG/y 2. Address (REQUIRED) % qoe-copt oz, *- 3. Contact Information (REQUIRED) Email: M obi lof"V11r-2 5 S ff.) a f Cell Phonq,.-".31`J !;-o1q— SA3 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) C2 b. Taxicab Business Name (REQUIRED) / VA a/L _u 5. Prior experience in transportation of passengers: 5 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When r— SIM17�cA '9, re; trr7, R44" s r�R 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 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? Type of offense 9. Have Where When,, to be an Iowa City taxi driver using a different name? If yes, please provide thhename(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) 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 valid Driver's license number 5 yc? / -i a" 7f - issued on4�piring on oa1.i 4Za C. 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 55, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicantt�/Ls� - Dated% STATE OF IOWA ) COUNTY OF JOHNSON ) ubs ribed and sworn to before me by Ertl %S 0 �_ on this �� day of Z2111P OLD/ 14 or'w� KELLIE K. FRU public in and a State of Iowa c Y C mi on Expires 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 1 .� V, - 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. 1 I IiL�ffih'I/ %�� Sign re of City Clerk or designee Office Use Only Dat N y Approved application o DCI report d State certified driving record N Website update77. jt N y-.....ai Cen✓rnxionwenocenPPLe2014amended.DOC 07/2016 tn4Oct��90 2016, 57PM 0 Div of Criminal Investigation uCi 1QhNNon..4846 P.�UUj 1/2 STATE OF IOWA Criminal History Record Check Request Form .j Tot lows lllvlelon of Criminal IovesliQation Support operallaoa Burma, le Floor 21S E. 7" Street pea Moines, tows 5039 (SI5) 725.6066 (515) 725•dm Far DCI Account Number. From) 'JLRalrw xl [IU 54%lews Or. Phone: 338 - Far:.. 315 35-1 0 1 ora r UrS(ln • un rawu'1 11111111x1 n1iw, Last Name inodmim) l�wvry r•••••.•• •.•. Fint Name lme dndn Middle Illamc raalnlnredod © Y Date of Birth mndln I Gender (n of 1 Social Seca Number (1oer1") 1�Male ❑Female . dR37 Wa1vdl /njormallan: Without ■ signed Waiver from the subject of the request, a eoloplele crlmloal biliary record away not be releasable, per Code of lows, Chapter 692.L For complete criminal history record informallon, at allowed by low, amyl obtain a W Iver simpature from lha subject or The r ual. Waiver Reld0.Tt: I htleey Blvd pwmlukn ftron rove reglmung vokol lawndlla in lm.1 aimiall frisky mrenl dwk wish de Division ofCdR iml Invupplivn(OCI). Any rsiminahllwrydera �n111u lMlbr sill IlnybmMWudlewad byisw. Waiver signature:, As of V\ a search of the provided name and date of birth revealed: ❑ No lows Criminal History Record found With DCI Iowa Criminal History Record attached, DCI b 6dG '.03J DCI initials Received Time Oct, 4, 2016 9:27AM No. 5333 mel M only) Oct. 9. 2016 3:57PM Div of Criminal Investigation No.4846 P. 2/2 ' IOWA CRIMINAL HISTORY DCI 00600361 MISDEMBANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED - 2016/10/09 DCI:00600361 NAME: STORY,BRREST ARTHUR DOH SEK RAC HOT WGT EYE HAIR SKN POB 19660227 M W 510 270 BED OLK MED MN ADDITIONAL IDENTIFIERS SC R EYE TAT LF ARM TAT R CALF TAT RF ARM TAT UL ARM TAT OR ARM CCH RECORD *** 01 ARRESTED 19990628 AGENCY: IA0570100 CEDAR RAPIDS PD CHARGE NO- 02 IA STATUTE IA708-2(4) SIMPLE ASSAULT TRK#: 500389102 COURT DISPOSITION AGENCY: IA057DISJ LINN CO DIST COURT COUNT NO. 02 IA STATUTE: IA708-2(4) SIMPLE ASSAULT CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 500369102 SENTENCE DISP EFF DAT PLEAD GUILTY 19990924 FINE $50 19990924 COURT COSTS 19990924 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION.OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED•TO NON -LAW ENFORCEMENT AGENCIES BY THE DCT. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION DOT SMARTER t SIMPLER 1 CUSTOMER MAN AN WVJbU IOWBCiQtgQV Office of Driver Services PO Box 9204 S Des Moines, IA 50306-9204 Phone, 515-244-91241800-532-11211 Fax: 515-239-1837 wwwJawadot,gov History Information Convictions Citation Date Conviction Date Certified Abstract of Driving Record Explanation Inquiry 10/20/2016 DL/ID #: 580XX9476 (IA) CDL Permit Class: None Date: IA 05/13/2012 08/28/2012 M14 Fall to Obey Traffic Sign/Signal Customer 1135116 Class: D CDL Permit Issue None #: IA Date: Name: Story, Ernest Arthur Audit #: 6719158 CDL Permit None Expiration Date: Address: 3507 QUEEN DR SW APT Issue Date: 02/22/2013 CDL Permit None 8 Endorsements: Expiration 02/27/2018 CDL Permit None Date: Restrictions: City/State: CEDAR RAPIDS, IA Endorsements:3 ID Status: None 524043894 Mailing 3507 QUEEN DR SW APT Restrictions: Corrective Lenses DL Status: VAL Address: 8 Restriction None CDL Status: None Mailing CEDAR RAPIDS, IA Supplement: CDL Permit ELG City/State: 524043894 Status: Date of 2/27/1966 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 02/19/2012 04/17/2012 M42 Improper Lane (changing lanes) Johnson IA 05/13/2012 08/28/2012 M14 Fall to Obey Traffic Sign/Signal Johnson IA 02/22/2013 05/30/2013 M14 Fail to Obey Traffic Sign/Signal :Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 06/25/2013 747232 IA 12/02/2014 831415 IA Name: Story, Ernest Arthur DL/ID: 58OXX9476 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: -�'�F111C1f ���ryr