HomeMy WebLinkAbout16-242IDENTIFICATION NO. %(s '_. `ZZ_
1 (Office Use Only)
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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
(31 91 356-5040
(319)356-5497 FAX
Firs Middle Last
1. Name (REQUIRED) t zdaeA h242 ,� �,r
2. Address (REQUIRED) N. % WQo� &K., '1 ,/q _
3. Contact Information (REQUIRED) Email: Cell Phone: 31 C�� / C/"
y
(All written communication sent via email) 76X -a " 651@IJ6?e-:
4a. Chauffeur's License expiration date (REQUIIRf D) v/r ;7, l2 �/y6
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: rrwy �Eili�rrvr7�
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6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /0
Type of offense
What happened to the charge? (Circle one) N6
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested/ charged with any traffic offenses in the last five years? Ale)
Type of offense
Where
When
What happened to the charge? (Circle one) /t/U
Convicted Dismissed Deferred Suspended Plead Guilty Other o
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?^
Type of offense Where (Vhen
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please provide Ihe-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)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page x
I hereby certify that I ave issued to me by the Iowa Departe t of Transportation a valid Chauffeur's license number
(p Qfrfi' _74 by
on 3/z V -expiring on l/9/Vn 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, Chapter2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant ��,I� " ' — Date
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STATE OF IOWA )
COUNTYOFJOHNSON ) pp—
Subscribed and sworn to before me by r ),zalntkL A e:y< on this Lo day of
. i. a 7_611 ff
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no infonnation which would indicate that the issuance would be detrimental to the safety, health orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Cade).
Expiration date of Chauffeur's license
Signatur, of B lice Chief or designee
M/C
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.
�i'12�iur• uff/
Signa of City Clerk or designee
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
CierwrnxioRiveanCenraLSM14am ded.00C 0311015
IMay: 26. 2016j:14AM�IarDiv of Criminal Investigation No. 5077 P, 5/5
" os/2oI2o'Is �-0: u..3 �161b r.vu2/ooi
STATKOF IOWA
Cliirnfital .History Remrd Check
Request ]Form
DCl Account Number:
µ(if appliosblc)
To: Iowa Division of Criminal Isivesllgation From: _ City of Iowa Cite
Support Operations Bureau, I" Floor City Clerk's orrice
315 E. 7" Street 410 E. 66'aihington Street
Des Moines, Iowa 50339
••• (5151725.6066 fou,a [_,_tv�d_5224➢—, ^
(51.5) 725-6080 Fax
Phone: 319-356.5041
Fax: 319-356-3497 '
1 am reouestinc an Towa Criminal Idiston' Record Check arr
Last Name Oiwidmo2)_ T
fir9tt )Namee (mandmo
Middle Nalttnne (Mummanded)
AS of search of the provided name and date ofbirtll revealed:
Date of Birth m9udAlol)'))
Gender (mn,datory)
Social Security Number (mommedd.d)
� q I 1 I ti 1
alstic male
.40-7 V-7 � /be700
Waiver Injorniafiau Withow a signed waiver from Ihd subject of the request, a complete criminal history record may not
be releasable, per Code orlown, Chapter 692.2. For co r fete criminal history record larormation, as allowed by lase, always
obtain a waivee sl nature from rue Sllbleet of there nett '
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Invsirigatims (DCI) My uindnal hissory dais conccminq mescal IIss�meinmined yds 0 1 may b. "lased st ailosod by law.
fPrriver-Sigtratu e: A* ZX U -
Iowa Criminal History Record Check Results
AS of search of the provided name and date ofbirtll revealed:
CE
No lova Criminal History Record found with Aril
® Town Criminal History Record attached, ACI4
ACI initials__
w
DCI -77 (08/25/10)
Received Time May 20. 2016 2:32PM No, 4707
.� r::: ra :._ DDT
vVinw,iowadot,gov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 8204 i Des Mofries, IA 50306-9204
Phare: 615-244-9124 i 800-532,1121 i Fax: 515-239-1837
www.loaadotgdv
Inquiry Date: 5/20/2016
Customer #: 6027595
Name: Fox, Elizabeth Ann
Address: 430 N 1ST ST APT 1
City/State: WEST BRANCH, ]A
Convictions
Certified Abstract of Driving Record
523589662
Mailing
430 N 1ST ST APT 1
Address:
D
Mailing
WEST BRANCH, IA
City/State:
523589662
Date of Birth:
9/19/1989
Sex:
F
Convictions
Certified Abstract of Driving Record
DL/ID #:
639AH2534 (]A)
LDL Permit Class:
Class:
D
CDL Permit Issue
=
Date:
Audit #:
9876415
COL Permit
Expiration Date:
Issue Date:
03/22/2016
CDL Permit
Endorsements:
Expiration Date:
09/19/2017
CDL Permit
Restrictions:
Endorsements:
3
ID status:
Restrictions: NONE
Restriction None
Supplement:
History Information
DL Status:
CDL Status:
CDL Permit Status:
CDL Cert Status:
CDL Med Status:
None
None
None
None
None
None
VAL
None
ELG
None
None
Citation DateConviction Date ACO Explanation County
__________ _ ____._. ._._.__._—____
10/21/2014 '01/28/2015 'S92 ;Speed Uohnson A
Name: Fax, Elizabeth Ann DL/ID: 639AH2534
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:
Name: Fox, Elizabeth Ann DL/ID: 639AH2534
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5/20/2016
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