HomeMy WebLinkAbout17-031rt.as�_
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319)356-5040
(319)356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. f % — (-) 3
(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
Middle
Last
2. Address REQUIRED Gil() N C:ooern r)- f" cl W(I c A5Z14�,
3. Contact Information (REQUIRED) Email: 11a11a�C >�L6� V0 110 j t 0n Cell Phone: 1161
(All written communi 1 n sent via email)
4a. Driver's License expiration date (REQUIRED) ? ^ Z _) 0 )-'1-
b. Taxicab Business Name (REQUIRED) -Yf ll r w Z�) 11 (' C-1 ("+y
5. Prior experience in transportation of passengers: 'I, rf �,f4 r' S t x. r iJer,
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
What happened to the ch e? (Circle one)
Convicte Dismissed Deferred Suspended Plead Guilty
Have you been arreste
arae
with any traffic offenses in the last five years?
Type of offense
Where
When
Other
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended lead Guil Other
8. Has your driver's license or chauffeur's license been suspended or revoked in th
iv
years? U i
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'nam0(til
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 ave issued to me by the Iowa De artment of Transportation a valid Driver's license number
�2 (, Q�-2_11 issued on xpinng on7)3 I /241), 1 understand that if I
falsely answer any ques ions in this application, that this application m 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 provisionisef-T#le 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of
STATE OF IOWA )
COUNTY OF JOHNSON )
Date i ' —17
Subscribed and sworn to before me by 11" h a 5 -7. LA) . ��r ��L on this LZ` day of
—C�ifuo�f.. U11
LA.?
WENDY S. MAYER Notary Public i nd for the State o Iowa
• Comm t�
.._.. 11H1HHH1Hf
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 Z ! 30 `?_rl
/2w—
Signature of Police Chief or designee
Wz3���
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.
ov
Sign@4e of City Clerk br designe
Date
-i
11HHflfN111H11HH1flfHllflf 1f11f11H111f11f 11fl1HlH!!Hf f 11ft1H11f11HHlH1H11fH1H1f111f1ii#f tfHflMlfHfi�f1tf1111f 1f 1H11
Office Use Only
Approved application
DCI report
State certified driving record
Website update
C,eWMIDRNBADG�92014"�ded.DOC 07/2016
C410WADOT
SMARTER 1 SIMPLER I CUSTOMER DRIVEN wWW'Iowadot.gov
Inquiry
Date:
Customer
Name:
Address:
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
2/22/2017 DL/ID #: 230AD2948 (IA) CDL Permit Class: None
5386301 Class: D
Jackson, Dallas Joseph Audit #: 8858609
White
920 N GOVERNOR ST Issue Date: 02/19/2015
City/State: IOWA CITY, IA
522455920
Mailing 920 N GOVERNOR ST
Address:
Mailing
City/State:
Date of
Birth:
Sex:
Convictions
Citation Date
12/02/2015
IOWA CITY, IA
522455920
7/30/1989
M
Expiration 07/30/2022
Date:
Endorsements: 3
Restrictions: Corrective Lenses
Restriction None
Supplement:
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
EXP
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status: None
History Information
Conviction Date ACD Explanation
01/05/2016---- - County JUR
F34 :Stopping on Traveled Way Johnson IA
Name: Jackson, Dallas Joseph White DL/ID: 230AD2948
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:
rFNlClf j nh
iy 2/22/2017
IOWA ' w
). O. T.;
f
'�� �� Office of Driver Services
+�� Iowa Department of Transportation
Frreu. IU. LVII,vIV:[)HIVIIcIorVIV 0 Criminal Investigation No. 3897 P. 1/1
02/14/2017 »:2. .•1331 .2/002
1
STATE OF IOWA
C"iminal History Record Check
Request ]Foran �
UCI Account Number: _ _ L.1 G' D'z�F
--(irappligble)
To: Iowa I)ivisiun of Criminal Jnvestigatlon From: Citv of Iowa Cit
Support Operations Bureau, 1" Floor City Clerlt's Office
215 C. 7'" Street
Des Moines, Iowa 50319 410 E. Washington Street
(515)725-606 lows ity-1;/-5
(515) 725-6080 Fax 2-240
C
-30
Phone: 319-356-5041
Fax: 319-356-5497
Name
MMale OFemale I f 1) — Za —
be releasable,
per Con: Without a signed waiver Oom the subject of%be request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain a waiver signature from the subiect of the request
Waiver Release: t hereby give permission rot we 2bolc
]nveetitabon (DCI). Any uimingl history 6212 wneeminame j
Waiver
to conduct an Lowe crimin2l Isinory record cheek wilh We Division ofCrimin2l
P The DCI may be roleased es ellmved by Inv.
As of�-? `�� a search of the provided name and date of bit1h trv,celed:
No Iowa Criminal 1-listory Record found with DCJ
EM
6J S\I1R0 Ullm run) yyglv,)r�yMVIJ f"lnr.l,�,V, /:/Vr rc _. ..
— n
�\ A
DCI iltitials J.JtJ
DCI -77 (08/25/10)
Received Titre Feb. 14. 2017 4:16PM No -3672