HomeMy WebLinkAbout17-079CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. ./-7— q9
(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
Irst ��jddle Last
1. Name (REQUIRED) ^ i� 7p S P-1 W n q EO�
2. Address (REQUIRED) 2 801 ../ Y�E_ — 3 / �'-mpkrta
3. Contact Information (REQUIRED) Email:+ome ke,Th� Or�Wkiii Phone I -C
(All written communication sent via email)) CoM
4a. Driver's License expiration date (REQUIRED) Te - 2oo 1T -
b. Taxicab Business Name (REQUIRED) 1p
5. Prior experience in transportation of passengers: ! Y
6. Have you ever been arrested / charged With any misdemeanors and/or felonies in this State or elsewhere?
Where
When o
512'-905 i
_ r
1 =t a
N
What happened to the charge? (Circle one) n- II=t Cn
Convicted Dismissed Deferred Suspended Plead Guilty -66
7. Have you been arrested / charged with any traffic offenses in the last five years? Yes i N
cn
Type of offense _ Where When
01�
..._I..- ._ ..._ ..... ,_�_ _.._, X15, <. / Zo Y
Convicted Dismissed Deferred SuspendedPlead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the e years? t1i O
Where
When
9. Have youever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
L
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
I` APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I here bV cerci �I/ have ss ed to me by the Iowa gpart ent o Transporta' n a alid Driver's license number
% 1 �o �O 3 issued on 1 � it g on 2026understand that if I
falsely answer any questions in this application, that this plica on may be denied. I agre 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 Ci Code. (FD
s to be signed in front of a Notary Public)
Signature of Applicant _ ate J 2 17
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by -Tl. ov- ca S L - 14Q m_+L1 on this Z Z day of
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 O
j 41 US
Signature of Polite Chief or designee
C>S2217
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.
CIeARA%IDRNSADGEAPPL92014amery W DOC 07/2016
of City Clerk or designee
Date
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Office Use Only
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Approved application
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DCI report
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State certified driving record
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Website update
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CIeARA%IDRNSADGEAPPL92014amery W DOC 07/2016
o5/14➢•19. 20173 2:57PM ab cDiv of Criminal Investigation
(FAX)31933s27(No. 9676 P. 1121.02
o CCroSTATE OF •
Criminal HistoryRecCheck
ord1 1
'•rt.,mg
Te( town Division OfCrinelrlal Investlgatlon
Support Operations Bureau, P Floor
215 E. 7" Street
Des Molnes, lown 50319
(SIS) 725-6066
(S)S)'725.6080 Fox
DCI Account Number: 9967-F
(TrapplIceblo)
From; Yellow Cab of Iowa City
, ..
pBOX-428
Iowa City, 1A, 52244
(319) 338-9777
Phone.
Fa>r (319) 339-7302
Lnst name (m.ndale ) FIr6t Name mandato Middle N me (reeommetdsd)
H E5A-r H T1aoM�5 �Dw,gRl�
Date of Birth rhmd0]cryy)) q Gender (mendele 'SooLi! / ! a�l-S�jou/ eouri tyjNumberruommone1ddad)j
Wale ❑Fehsale — 2 "+�r(rC7 6
Walver Inforrrlaripn. without a signed waiver from the subject of the reelvest,A complete 4rlminal history rodord may not
be rolonsabie, pop Code of Iowa, Chapter 692.2. For complete criminal hlstory-rocord Information, as allowed by Ipwl always
WafVCr Rd1taSC; I hereby give pOrmllslon rer the above rcquallna Mole] 10 conchal In laws Ofllnfnsl historyreoord chock wlrh the Division of Criminal
Invaligedon (DCQ. Any crlminel h1vory data concorniea me Thal Is melnlelaal by Ihl DCI may, be rolelsed ase11ow011,byjaW,
Walver S7gnartura;
As of 5 l I R l 11 , a search of the provided name and date of birth revealed;
--'Eno
No Iowa Criminal History Record ,found with DCI
❑ Iowa Criminal History Record attached, DCI #
DCI initials
OCIM (08/25/10)
Received Time May, 15, 2017 2:58PM No. 0590
•.x
(DC( use only)
I
raga i ui L
C 4%
410WADOT
SMARTER 15IMPLER I CUSTOMER DRIVEN www'ioWadog V
Office of Driver Services
PO Box 9204 I Des Moines, IA 50306.9204
Phone: 518-244-9124 1800-532-11211 Fax: 515-239-1837
www.iowadol.gov
Inquiry
Date:
Customer
Name:
5/12/2017
915880
Certified Abstract of Driving Record
DL/ID #: 769YY6103 (IA) CDL Permit Class: None
Class: D
Heath, Thomas Edward Audit #: 1807951
Address: 2801 HIGHWAY 6 E LOT Issue Date: 05/12/2017
394
Expiration 05/19/2025
Date:
City/State: IOWA CITY, IA Endorsements: 3
Convictions
CDL Permit Issue None
Date:
CDL Permit
522402658
Expiration Date:
Mailing
2801 HIGHWAY 6 E LOT
Restrictions: Left and Right Outside
Address:
394
Mirrors
None
Restrictions:
Restriction None
Mailing
IOWA CITY, IA
Supplement:
City/State:
522402658
;IA
Date of
5/19/1959
Birth:
Sex:
M
History Information
Convictions
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Explanation
CDL Permit
None
Endorsements:
07/18/2013
CDL Permit
None
Restrictions:
IA
ID Status:
None
OL Status: VAL
CDL Status: None
CDL Permit ELG
Status:
CDL Cert Status: None
CDL Med Status: None
:itation Date
Conviction Date
ACD
Explanation
County
3UR
)7/07/2013
07/18/2013
'S92
Speed
Linn
IA
12/27/2015
_
ol/27/2016
;M14
Fail to Obey Traffic Sign/Signal
3ohnson
;IA
Name: Heath, Thomas Edward DL/ID: 769YY6103
Pursuant to Iowa Code §321.10, 1, 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:
p@�F91CLf p��i�y
IOWAtr4
5/12/2017
D.0.T.�Y ,
�f
/�4�Oi t••••_�C�a'
5/12/2017