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HomeMy WebLinkAbout16-243i �III� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. i Le -7Z,4:5 (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 First 1. Name (REQUIRED) u Z L 2. Address (REQUIRED) Middle 3. Contact Information (REQUIRED) Email: Cell (All yvri(te c m n cat t via email) 4a. Driver's License expiration date (REQUIRED) "-_a La — a D;� p b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended PleadGuiltyOther Have you been arrested / charged with any traffic offenses in the last five years? V W 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? /j U Type of offense Where When, �t 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please lrbvide t e nam (s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE:CIRTIFIED 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 Transpo and on a va Driver's license number T,9 LP Ll a CIU ©4 �> I issued on ]P- ISI- expiring on I understand that if I falsely answ a%iy 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 provisi s of Title 5, Chapter 2, e City Code. (Needs to b/e^gned in front of a Notary Public) Signature of Applican U !� Date L/ ! o !111!1!!1!1111!!!lwffffffffffffffffr»11!11111-f»fllfllfllflllf!l1f111111!111111f11f111f+fffffff!!llffffflffffflfffffllflf!!f«111r11f1!!!!llfll STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by SU -z—', is 0-- , on this — day of Dc.ftAae ai -z01 LP I n , j I . . vtEAM in and for the State 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 /�6z i 125// Date 1 Signature df P61iceChief 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. Signatute.Df City Clerk or designee I% e Date f I11111Mfl1fifofYflfllfflffflfflflf:IRfllfffffflff 111111 ff #fffiif f lffffflff 1111 f 111111 f4f 1111111lfMllf!l1Mlf11ff�fYl111f111f1MMlXff f f O� Office Use Only C N � n U'1 Approved application :<r— DCI report -r , r State certified driving record Website update N GerkrMURNBADGEAPPL92014e dW DOC 07/2016 .UCte 1/. 2016 10:41AM Div of Criminal Investigation No. 5472 P. 1/1 10/ra'cu w w;2crel,uw Cab u, luwa u,ty (FAX)3193382:uo r.uu2/002 OF • WA I Criminal History Record Che Request Form Tor Iowa DivUlon of Criminal Investigation Support Oporatlons Bureau, 1sr Floor 21S E. 7" Street Deo Molnes, Tows 503)9 (515) 72S•6066 (�15)72S•6090 Fax I am rams CAtino, nn tnurn r.imiwel Vr • _. n� _-.. . DCI Account Number; 9967•F (If Applieablo) From; Yellow Cab of Iowa City P.O. Box 426 Iowa City, L1. 52244 (319) 338-9777 Phonon Faxi (319) 339-7302 Last Namemandoto First Name (mandatoI Middle Name voommendee Date)of Blyth fm)tnddeiory) As of l d I / / 1!e , a sol roh of the provided name and date of birth revealed: Gender mandno 'SOCi4l. Security Number(reaammmded) ©Mala k0ma.16 Waiver Information, Without a signed waiver from the subject of the request, o eomplpto grlminal history record rpny not be raleesabit, per Code of Iowa, Chapter 692.2, For cam plate criminal btstory,rcoor(1 information, at allowed by law, always obteiu a waiver signature from the sub ect of the re uest. Waiver Release: i herebyglve permission rot the above requesting otllelel to conduct in laws criminal historyrecord check with the Division of Criminal Invostiguiion 0Q. Any criminal history date conwml me [he[ b aln[ ed by the DCi ma he r-1 sued as allowed by low. Waiver Slgnafure• -- ... wwnv vaT J. WV WLu vl/Mar1\A\WLLLL0 (DCT use only) As of l d I / / 1!e , a sol roh of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI - 'C ❑ Iowa Criminal History Record attached, DCI a-- DCI initials DGI-77 (03/25n0) Received Time Oct. 13. 2016 10:380 No. 6032 Page 1 of 2 �, ►DOT SMARTER 1 SIMPLER wwwkwadotgov I CUSTOMER DRIVEN office of Driver Services PO Box 9204 i Des Moines, IA 50306-9204 Phone: 515-244-912418DD-532-11211 Fax: 515-239-1837 www.Madot qov Inquiry Date: Customer Name: Address: 10/14/2016 884476 Brayton, Suzi Certified Abstract of Driving Record DL/ID #: 642YY0437 (IA) CDL Permit Class: None Class: D Audit #: 1365022 1728 GLEASON AVE Issue Date: 10/14/2016 City/State: IOWA CITY, IA 522405915 Mailing 1728 GLEASON AVE Address: Mailing IOWA CITY, IA City/State: 522405915 Date of 7/26/1972 Birth: Sex: F Expiration 07/26/2022 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Brayton, Suzi DL/ID: 642YY0437 CDL Permit Issue None Date: CDL Permit None Expiration Date: None CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: None CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None 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: mp `1 N %4, 10/14/2016 �� �: IOWA • •SSS `°:. CDCil -1 ry�,��®% ^••" Office of Driver Services Iowa Department of Transportation"i J'''o Name: Brayton, Suzi DL/ID: 642YY0437 N -T1 10/14/2016