HomeMy WebLinkAbout17-013ASG®dJ�
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
Q 19) 356-5040
(319)356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. ( — (-? 1 ,h
(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
3. Contact Information (REQUIRED)
(All written communication sent
4a. Driver's License expiration date (REQUIRED) / 6 T-1Y0q'. 147
b. Taxicab Business Name (REQUIRED) f7 I� cl %t)
5. Prior experience in transportation of passengers:
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty
� /Other
Have you been arrested / charged with any traffic offenses in the last five years? i'�
ST eofoffens Where When
I If, -X0 (021/4
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked int a years?
Type of offense Where When
9. Have
applied to be an Iowa City taxi driver using a different name? If yes, please provide thp,Aamos) r
0
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 he� rt t I lave is ped to me by the Iowa D�p�dp�e of Transportation valid Driver's license number
}S ``: issued on tz � expiring on Z _ . I understand that if I
false y 5insweY Any questiong in this application, that this application may be denied. f 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 pro visiQ�n/s,of Title 5, Chapter 2 of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant f\�� S Date 4512- 71
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by K tnl aL.. &,t . Ail &p on this day of
TAµuar.. t-47'2
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' i' y of Iowa City (Title 5, Chapter 2, City Code).
Ws license—U %r ti l 21
I / p
11
or designee Datib
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.
natur
�of City Clerk or designee
Date
DCI report
State certified driving record
Website update
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Office Use Only
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Approved application
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DCI report
State certified driving record
Website update
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�%� I® D O� www,iowadnt.gov
SMARTER I SIMPLER I CUSTOMER DRIVEN office of -river serviCees4
PO Box 9204 i Des Moines, IA 50306-92
-239-1837
Phone: 515-244-91241 800-532-1121 I F1www.wwadol9ov
Certified Abstract of Driving Record
Inquiry 1/10/2017
DL /ID #: 769YY0847 (IA) CDL Permit Class: None
Date:
Customer
Name:
Address:
4292418
Class: D
Allison, Kevan Michael Audit #:
621 1/2 BROWN Issue Date:
City/State: IOWA CITY, IA 52245
Mailing
621 1/2 BROWN
Address:
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Mailing
IOWA CITY, IA 52245
City/State:
Office of Driver Services ortation
Transp
Date of
11/29/1961
Birth:
Sex:
M
9136520
06/03/2015
Expiration 11/29/2022
Date:
Endorsements: 3
Restrictions: NONE
Restriction None
Supplement:
History Information
Convictions
Citation Date
Conviction Date _ ACD_
_ _ _ — --
11/14/2015 102/11/2016 1S92
r
Name: Allison, Kevan Michael DL/ID: 769YY0847
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
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CDL Permit
None
Endorsements:
Office of Driver Services ortation
Transp
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
n
lavation Count _ _ _ ty JUR - --
Johnson iIA
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Departmtrue ent and
Transportation, do
er
ans Is
rofficial r that I am the
currently n custodian of the records
of said office,eld by the Office of and that I have been authorized uthori eld by the Diriectorof the Iowa cDepartment 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:
�;!:'•• .ft t,
• ,�
1/1,0//2017
�,
IOWA 4G
T.
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DENE-
Office of Driver Services ortation
Transp
Iowa Department of
FrJan_13. 2017 9:16AMcig,Div of Criminal -Investigation 01/10/201-/ ,a:sNo.1184,ea F. 1�1/ooz
STATE (DR 10WA
t l Ca•brr nal< History Record Check
r Request Forin
c
DCI Account Nun)ber: tloo 7-r'
(If applicable) -----
To: Iowa Division of Criminal Investigation From: City of Iowa Cites
Support Operations liurean, V Floor City Clerk's Office
215 C..)" Street 4101',. Washington Street
Des Moines, Iowa 50319 ^^
45151 725-6wg .... Iowa City, IA 52240
(516)725-6000 Fax
Phone: 319-356-5041 _
Fax: 319-356-5497
1 am rennestine an Iowa Criminal History Record Check on:
Last Name (mandntery)
First Name (mandatory)
Middle Name (recommended)
C( `,sal
_
,C
Date of Birth (mandatory)
Gender mmindmory)
Social Security Number, (reeommended)
'
112 7 (j
AJiS4ale OFemale
g 9 6 3 9
Waiver Information: without a signed waiver from thesubjeet of the request, a complete criminal history record may not
be releasable, per Code orlows, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain a waiver signature from the stlblect of the request.
Waiver Release: ) hereby give permission for ase above regnudng official to conduct an Iowa c6mioal history Acord check with ftbivisien oretimiaal
hwestigatiaa(DCT). Any uiminal history data conceosing nm that it maintained by the DCI cony be released as allowed by low.
WaiverSigxnfare:VQA- /rA M `-L ^
1V Wed%,A 1A/111X41 ALL l3 LU A Y 1\OVUl t1% 11 FZUA Beau! as (I)CI ntc only)
As of 1III a search of the provided mine and date of birth revealed;
-- No Iowa Criminal History Record found with DCI
® Iowa C)iminnl History Record attached, DCI #- y,
r;
DCT initials C k —
13101-77 (005/10)
Received Time Jan, 10. 2017 1:35PM No. 1230