HomeMy WebLinkAbout17-038A
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240- 1826
(319) 3S6-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO./ % — D3 Fj
(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) Email:
4a. Driver's License expiration date (REQL
b. Taxicab Business Name (REQUIRED)
(All
sent via email)
Cell Phone:-ilI(-(ba
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
7. Have you been arrested / charged with any traffic offenses in the last five years?
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? K6
Tvoe of offense
Where
When
9. Hav you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide thename(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 here y.p rt' at have ssued to me by the Iowa Depa ment of Transportat' n valid Driver's license number
1��� (4 issued on I expiring on I understand that if I
falsely answer any questions in this application, that this app icay be denied. I agre that in making this application, I
consent to allow agents or employees e Cijy o Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to thi licatio , and I u r ree that, rf authorization to be a taxicab driver is granted, to comply at all
times with all of the pro isions o Titl 5, C r! the City Code. (Needs to be si ed in front of a Notary Public)
Signature of Applicant Date
i'
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Qj� ; a }� . )�21� Q �4 on this day of
fin( 9, rJl^j.
uiwDY S. MAYER
Public inland for the Stat®of Iowa
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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 o Ipwa City (Title 5, Chapter 2, City Code).
I Z/ 3 // 21
03- 0 Y"/
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.
Signature of City Q4erk or designee
U
-/7
Date
1HHHIHHHHHM111Hf11f1111f11f1111111fHifit111HiHHHHHHIHIlHf11fM1Nf1111111111111f111111f Hf
Office Use Only
Approved application
DCI report
State certified driving record
Website update
0eh✓rAXIDRN94DGEMR920149m ded.DOC
07/2016
Iowa Department of Transportation
L8not5cp d (jma swig y (loll ffeo) 50MU-1121
PO 6ml 8204, Oes mom,U 5Q.i0b82111 515.239.4121
FAX 516439-1837
Convictions
Citation Date
Conviction Date
Certified Abstract of Driving Record
Ex lanation
Inquiry Date:
3/8/2017
DL/ID #:
296AE8795 (IA)
Customer #:
2701866
Name:
Kelley, Brian Patrick Class:
D
ID Status:
None
Address:
1520 TRACY LN
Audit #:
8788593
DL Status:
VAL
Issue Date:
01/23/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
12/31/2021
CDL Cert Status:
None
522405832
Endorsements:
3
LDL Med Status:
None
Mailing Address:
1520 TRACY LN
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
12/31/1982
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522405832
History Information
Convictions
Citation Date
Conviction Date
ACD
Ex lanation
lCountv
3UR
105/26/2015
06/19/2015
1 M34
1 Following Too Close
Johnson
IIA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
I Case Number
JUR
105/26/2015
860746
IA
Name: Kelley, Brian Patrick DL/ID: 296AE8795
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:
02Ma:. 1. 20172 4 24PM
f
01
Div of Criminal Investigation No.4778 P. 2/2
4 DCI IOWA 10004
STATE OF IOWA
Criminal History Record Check y .
Request Form
To: Iowa DMdou of Comhlai lavatlsanan
SoPPw Operations Ibueaa, Ir Floor
113 L 1" Strad
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First Name l
Middle Name
Date of i
Gesdair
$octal Npnber
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le OFemale
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As of 311 a aoarrlr of the provided name and date of Will: revealed:
No Iowa Crindul History Record found with DCI
.a
❑ Iowa Criminal Histoy Record attached, DCI N
DO initla/r
Received Time Feb. 28. 2017 11:14AM No.4514