HomeMy WebLinkAbout17-090CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa S2240-1826
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. /-7-'D'GD
(Office Use Only)
APPLICATION FOR TAXICAB I 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
2. Address (REQUIRED) 13
3. Contact Information (REQUIRED) Email:
written communication
4a. Driver's License expiration date (REQUIRED) -
b. Taxicab Business Name (REQUIRED) W.1
5. Prior experience in transportation of passengers:
Phone: 3 P -5jS al a7
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? 1rNpr,�C
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? lh!2�
Type of offense Where When
N
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prjei8 thtftme(s)
r11 A Dy r
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT0PRTfPkD I"
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE rFMF R&VIEV1�
o� a
You must apply for an individual Department of Criminal Investigation Report (form ay.* a uppn rec l=t).
Crt
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) `"
07/2016
l
J APPLICATION FOR TAXICAB VEHICLE DRIVER
Paae 2
I herebcertify that I have issued to me by the Iowa D part ent of Transportation Ivajid Driver's license number
b'1 � issued ons j to expiring on C ) Y JVQ jQq I understand that if I
falsely answer any questions in this application, that this application may 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant «J Date a �9111-1
!Hlfffw++4l1111H++++4++++a++}a}4}a4xwxxw}Tlxwx!!lH11l++#TaxTlHlx!l1HHRH+++++#xw++1H1H1Hx1HwH4#+HlfHw###}#a}x!x!+}TwlH#44x+++#yH
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 4y,E,Qa ,O. &Irce� on this 7 day of
-5-1,C6Lr -7_A=,/7.
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 �&[ �V2jY
13�4L.
Signature of Police Chief or designee
-717117
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.
Si nature of City Clerk -or designee
l
7-7-1
Date
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O_
Office Use Only o '_T1;0 C
Approved application C -)n r
DCI report cr 1. M
State certified driving record {f*t v
Website update
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CJ n AwoRNBADGEAPPOM14x� DOC 07/2016
State of Iowa
Division of Criminal Investigation
215 E. 7" Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 515/725-6080
mequesnng an Iowa criminal history record check on
Last Name imij do TL'.....a wT— _
Fill in all shaded areas.
6rte-n 4 Y -d VLA ;a
e of Birth Fecha Nacimiento (mandatory) Gender Gen..
O q% flv I I I � Q I ❑ Male Female
Waiver Signature Firm, (If the request is on yourself, please sign. If the request Is on Someone else, w ite N/A.)
Results
DCI USE ONLY
As of jp a name and date of birth check revealed:
?No record found
❑ Record attached DCI #
DCI initials
Receipt
Number of requests i
Method of payment: iC
Cardholder's name
DCI initials he,
----------------
Credit Card #
X $15.00 per last name = Total amount $ k `s e
rag
cash money order check #
MtterCMor visa
( 4 digitQ..�
C-3
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a ..
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o—
------------------------------------------------------------—
- -� -----------------
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Exp. Date
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
1
4001 140"k'WA 00T
www.iowadotgov
SMARTER I SIMPLER I CUSTOMER DRIVEN-- ----- -
Inquiry 6/28/2017
Date:
Customer 4514610
Name: Green, Andria Jo
Address: 412 4TH STREET SW
City/State:
CEDAR RAPIDS, IA
End
52404
Mailing
412 4TH STREET SW
Address:
Suspended
Mailing
CEDAR RAPIDS, IA
City/State:
52404
Date of
4/4/1972
Birth:
Sex:
F
Sanctions
Page 1 of 2
Office of Driver services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1 800-532-1727 I Fax 5f5-239-7837
www_towadot.9pv
Certified Abstract of Driving Record
DL/ID #: 075BB5722 (IA) CDL Permit Class: None
Class: C
Audit #: 1212165
Issue Date: 08/09/2016
Expiration 04/04/2024
Date:
Endorsements: NONE
Restrictions: NONE
Restriction None
Supplement:
History Information
CDL Permit Issue
Date:
CDL Permit
Expiration Date:
CDL Permit
Endorsements:
CDL Permit
Restrictions:
ID Status:
DL Status:
CDL Status:
CDL Permit
Status:
CDL Cert Status:
CDL Med Status:
None
None
None
None
EXP
VAL
None
ELG
None
None
Type
Effective
End
ACD
Explanation
Occurrence JUR
JUR
Suspended
,08/24/2010
!05/31/2012
D53
.Non -Payment of Iowa Fine
;IA
IA
Name: Green, Andria Jo DL/ID: 075665722
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
this date:
of the Department to be set upon this document,
at Ankeny, Iowa
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6/28/2017
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Office of Driver Services
Iowa Department of Transportation
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6/28/2017