HomeMy WebLinkAbout17-076r~
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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. ) ! -07CP
(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
Last
i, Q N
2. Address (REQUIRED) l `I sy / S. C;
3. Contact Information (REQUIRED) Email: ccItQ4ec C C rhsh.c.owr Cell Phone: 3i9 3aSS-.SUIO
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED)
30 2va
b. Taxicab Business Name (REQUIRED)
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? /Vv
Type of offense
What happened to the charge? (Circle one)
Where
When
N
Convicted Dismissed Deferred Suspended Plead Guilty Other 2
/ 7 /
Have you been arrested / charged with any traffic offenses in the last five years? M a
Type of offense Where gt n —
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? / L16
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(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
I APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Cepa ment of Transportati n valid Driver's license number
005' WW `iA36 issued on 5 �3 r expiring on Y �o �oau 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, f 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 i --- Date
STATE OF IOWA )
COUNTY OF JOHNSON ) I I
scribed and sworn to before me by k ri Sias r RE rti r, on this day of
a`t4,, KELLIE K. FRUEHUNG
_c«nRussonN"rb. 21819 otary P lic in and for the St 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 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.
Cigna fe of City Clerk or�esignee Date
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Office Use Only
Approved application
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DCI report
State certified driving record
Website update
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07/2016
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05itMay.16. 2011; 3:42PM Div of Criminal Investigation
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a DCI Iolv,No. 9434 P. 1/4
(111),
STATE OF IOWA "t
Criminal History Record Check M
Request Form
Tot Iowa Divlden orCrlmin■t Investip itol
Support Opentlone Harean, l"Floor
219 8.9' Street
Bell Moin&,,laws 40319
(518) 725.6066
(613) 7:5:6080 Fa>t
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Phone: ,(91a 335- "q
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Gender
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Waivrr 1grbrn&diup: Witbaat a alined waiver foal the subject of the request, a complete crinlnal history ward alleynat
be rmieaubie, per Code of few:, chapter M2. For galulfj9 ctltalual history maid Information, a Wowed by taw, always
obtain a Welvarlijontrafrom ibeaab art oltho r at•
Waiver L;dMe:I heahy sive pembtaton for the Amtam eaiogoaciet to eaoWN. mom rrimlorl hh4ayrawd anew eith danl•Won of cdaloel
1pw dpdw so(M Any admind 10 e y fan mooemhy�ia mairained by Ow rr( mull: mtmal as d laxed by la W.
Waiver Siparre-e:
As of S a search of the provided name and date of birth revealed:
INo lowaCrlminal history Record found with DC1
❑ Iowa Criminal History Record auaohed, DCI #
DCl
Received Time May. 11. 2017 1:08PM No. 0396
,rL,Ji6iAiAD0T
SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWaCJOt.gOV
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1 800-532-1121 1 Fax: 515-239-1837
www.bwadof.gov
Certified Abstract of Driving Record
Inquiry Date:
5/18/2017
DL/ID #:
005WW9836 (IA)
CDL Permit Class:
None
Customer #:
4138394
Class:
D
CDL Permit Issue
None
Date:
Name:
Bergan, Christopher Charles
Audit #:
8006344
CDL Permit
None
Expiration Date:
Address:
1950 S GILBERT ST APT 7
Issue Date:
04/23/2014
CDL Permit
None
Endorsements:
Expiration Date:
04/30/2020
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522404310
Endorsements:
3L
ID Status:
None
Mailing
1950 S GILBERT ST APT 7
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522404310
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
4/30/1965
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Bergan, Christopher Charles DL/ID: 005WW9836
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:
��yr
5/18/2017
IOWA'°y
0.
......Office
DR
of Driver Services
Iowa Department of Transportation
Name: Bergan, Christopher Charles DL/ID: OOSWW9836