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HomeMy WebLinkAbout17-066�'r"III CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. / Z —nt 0 i D (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAS 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) 4a. Driver's License expiration date (REQi b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: amQ , 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? nye 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 chauffeurs license been suspended or revoked in the last five years? Type of offense Where When 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please pi"eyl mw— Sy Dy � DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STRRTIFIED r DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE - FFR 1/IE 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 h�ere=l y �ertt�rfy%t�hAI have issued to me by the Iowa De %n��utof Transportati nQg la/valid river's license number �J(J� issued on xpiring on Q 1 understand that if I falsely answer any questions in this application, that this application may be denied. I agree that in making this application, 1 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date1' 1111fHHfHHfltYlHH1fl11H14HfHHHHH1flHfHHi]fHHf41fHHH1fHf t4ftf4HHH4iHHHlHfflHlffff4Yf#44fHff1f YI4M1!lhfl44flf14Hii4 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and 7W to before me by A& f i ra v\ on this day of k, I tr 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 08 • 0/ • Zo to 4-/2�1JL_ Signature of P61A Chief or designee OS•01-201 -7 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. 3�_ -�1, , of City Olerk or designee Office Use Only Approved application DCI report State certified driving record Website update Date N n -- J geNJTAXIERIVBADGE WL92014a.ded.DOC 07/2016 s v o D geNJTAXIERIVBADGE WL92014a.ded.DOC 07/2016 041Apr.27. 20173( 2:46PMCab,Div of Criminal Investigation STATE OF IOWA @) Criminal History Record Check Request Form To: Iowa Division of Criminal investigation Support Operations Bureau, I" ploor 215 E. 7je Street Des Mollies, Iowa $0319 (819)729-6066 I am recuestin¢ an Iowa Crlminal Mntne a. -...a rh.,.t. — (FAX)31933327No. 8076 P. I/1.002 ACI AcoountNumberl 9967-F .... (Ireppllcabte) 1From( Yellow Cab of Iowa City P.O. Box 428 Iowa City, IA. 622 4 Yhonet Fax: (319) 339-7302 ;QUI Last Name (mandato Fir-$ Name mandato Middle Name recommcndod) Lin 1pci n a n 19-rn ua Datto of Birth (mudolotn�o) Gender mmdato ) $oaln/]JSecuri Number neomme.ded 0a U I q I OMa1e Fermis g I q' oa(p--'a WdlvefWordtdllon: Without a signed waiver from the subject of the request, a dompletc orlminel history record may not be releasable, per Code orlowe, Chapter 692,2. For om Iete criminal history record Information, as allowed by law, always obtain a waiver si nalure o the subject orthe rehest.. Walvar.Release:I hereby give Penticton for the above mqueulna emdal to'Oonduct An IOWA eeimlnal Meorynwid chock Willi the Division orcdmltW Invelligulon (OCn,.'My criminal history data concerning me that is melntdned by tho DCI msy be nieaud es dlowed by le(a. — lVai'erSlgnalurs.--DAA IOVA , j}yl --ma u ti ate . p A%atauatA (DCluse only) As of `+T " sail I . a search of the provided name and date of birth revealed: N• O ase' ! No Iowa Criming History Record found with DCI © Iowa Criminal history Record attached, DCI # DCI initials x DCI -77 (08/25/10) Received Time Apr. 25, 2017 1:47PM No, 7860 CIowa Department of Transportation AW Office d Dinrer SerAm (Tdi Free) 80Q-532.1121 PO 8W 8204, Des fAMM, 1A503059204 5152448124 FAIL- 5152391037 Certified Abstract of Driving Record Inquiry Date: 4/25/2017 DL/ID #: 060BB4823(IA) Customer #: 4522778 Name: Long, Adrian Amara Class: C ID Status: EXP Address: 1100 ARTHUR ST Audit #: 1280070 DL Status: VAL APT 03 Issue Date: 09/06/2016 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 08/01/2020 CDL Cert Status: None 522406620 Endorsements: NONE CDL Med Status: None Mailing Address: 1100 ARTHUR ST Restrictions: NONE Restriction None APT 03 Supplement: Date of Birth: 8/1/1991 Mailing IOWA CITY, IA Sex: F City/State: 522406620 History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 103/26/2015 851869 IA Name: Long, Adrian Amara DL/ID: 060BB4823 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 wltness whereof, I have caused my signature and the seal of the Department to be set upon this docume;!,, at Ankeny, Iowa 0 this date: s -'n 4/25/2017 C- Office of Driver Services ��ww�� Iowa Department of Transporation Name: Long, Adrian Amara DL/ID: 060884823 N :R: m • 1 -< r-- rn -o rn s �' O