HomeMy WebLinkAbout17-067IDENTIFICATION NO. j —1 —bt o—1
l 1 (Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Sl reel
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(3 19) 356-5497 FAX
i s r /� die �s�
1. Name (REQUIRED) "� <O
2. Address (REQUIRED) 1i%� 4� r-7 11rP � j
3. Contact Information (REQUIRED) Email: o,h Q VhJ a� WW 7I � c Cell Phone:
(All written communication 66nt via email)
4a. Driver's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) Ye /i 4
5. Prior experience in transportation of passengers: 2z -( PGI )- S
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? e
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? A V
Type of offense Where When d
_ J
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prev� ins the;mme(�;
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFM
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVgW
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 hereb certify haze issued to me by the Iowa Dgpartm nt of Transporta io a alid river's license number
�%�/ � '/ Ir.7 issued on QJ� expiring on 2 Z 2 . I understand that if I
falsely answer any questions in this application, that this app6cati'06 may be denied. I gree, hat 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 provis, of Title,,5, Ch pter 2, of the Cit de. (Needs to be signed in front of a Notary Public)
Signature of Applicants Date
STATE OF IOWA )
COUNTY OF JOHNSON 1
S scribed and sworn to before me by -1i"iGl� �G �eh on this day of
17 � )
a`ee KELLIE K. FRUEHLING ._- <l z .� /� +.U-2 �LL q
and foythl~ State of Iowa
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
Signature of Police Chief or designee 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.
Signatute of City CI rk or designee Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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04 1A 19. 20112 1:09PM Cab Div of Criminal Investigation
STATE OF IOWA
Criminal History Record Check
Request Form
(FA%)3193382:N0. 8656 P. 1/1,,Q02
DCI Account Number: 99¢7-F
�- (Iroppllcable)
To: Iowa DIvldon otCrlminal Invoetlgetlon From: Yellow Cab of Iowa City
Support Operations Bureau, I" Floor P.O. Box 428
215 E. Ila Street
Des Moines, Town 50319 Iowa Clty, IA. 52244
(516) 725-6066
(Sig) 72 5-6090 FAX (319) 338- 1
Phone.
Fax: (319) 339-7302
, _ - r....- ra_l..I .vl......, U ---A l.L...L .....
Lost Name Mand
First Name (mandatory)
Middle Name (laaamendeu
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Date of Birth (Mandaro
Gender (manduo
Social rmornmeh do d
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�7Glale ❑Female
�ssourliVNumber
/ `lamlet
Walv r,roormati n; Without a signed waiver from the subject of the request, a eomple(e criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2, Ver complet criminal history record information, as allowed bylaw, always
bUM a waiver sl nature from the subject of the re ueat..
Waiver Rlele2Se:lhembyalvepotentiation for Ne vorequcalnaamalaltoeondueianlot"cftnalhl Dry rceordcheck With. d,oDlvblonerc"nat
Invatilaollon(DCI), Any criminal hindry data cona e1)smontaln ythoDClmayb eleaeed ovadbylow.
Waiver Signature: '24
As of (--4- — Tai — 12 , a search of the provided name and date of birth revealed:
ct� No Iowa Criminal. History Record found with DCI
❑ Iowa Criminal history Record attached, DCI #,
DCI initialss
DCI -77 (08125/10)
Received Time Apr. 11. 2017 MIN No.7333
(DCI use only)
A- Iowa Department of Transportation
Oboe at Drnar Selvlces (Toil Flee) 800.532.1121
PO Boot 9204, pay MMM, LA 50306-9204 515-244-4124
FAIL 615-239-1837
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
4/17/2017
DL/ID #:
701YY1753(IA)
Customer #:
2857327
Name:
Madden, Patrick
Class:
D
ID Status:
None
Speed
George
IA
Address:
3009 12TH AVE SW
Audit #:
1549858
DL Status:
VAL
APT 102
Issue Date:
01/13/2017
CDL Status:
None
City/State:
CEDAR RAPIDS, IA
Expiration Date:
11/22/2024
CDL Cert Status:
None
524041460
Endorsements:
3
CDL Med Status:
None
Mailing Address:
3009 12TH AVE SW
Restrictions:
Corrective Lenses
Restriction
None
APT 113
Supplement:
Date of Birth:
11/22/1950
Mallin y
CEDAR RAPIDS, IA
Sex:
M
City/State:
524041459
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
CountylUR
05/03/2013
05/30/2013
M42
Improper Lane
(changing lanes
Johnson
IA
04 04 2017
04/06/2 17
S92
Speed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
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Name: Madden, Patrick George DL/ID: 701YY1753 � a
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Pursuant to Iowa Code 4321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Departrn Hf Transportatipy�-otn�. do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a*K)Fnd aggurate FQ of
an official record currently in the custody of said Office, and that I have been authorized by the Directc6q& Iow=a DepAUnt
of Transportation to so certify. ,
In witness whereof, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
`r+jffi;(f 4 4/17/2017
'Iowa
D. 0. TIlk .
PrOffice of Driver Services
� Iowa Department of Transporation
Name: Madden, Patrick George DLAD: 701YY1753
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