HomeMy WebLinkAbout17-075r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. 11 - 0'7 S;
(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
First Middle Last
1. Name (REQUIRED) SAMJE/'42SeAJ
2. Address (REQUIRED) FO/ 5 . 4 ✓C Idej-4cla /,¢ 5..221?0
3. Contact Information (REQUIRED) Email:wrsor Cell Phone: 319-5'!i-D/i1�/
All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) 02Al212m
b. Taxicab Business Name (REQUIRED) M4000S 74-X1
5. Prior experience in transportation of passengers: T&4YE f%L S f%S TrFXi .Dt-1 ✓C,?—
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Aho
Type of offense
Where
When
�c� a
What happened to the charge? (Circle one)
r
Convicted Dismissed Deferred Suspended Plead Guilty -j her _
A
Have you been arrested / charged with any traffic offenses in the last five years? /� _ fir-' s r t
C:3 '�—
Type of offense W here„W hen-
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?
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
APPMCATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportatioq� a valid Driver's license number
`l�'/zzo5-,7' issued on o2/z3//3 expiring on t%2/Isz/iF . 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 Applican -- Date 5, tX f -7-
t%
STATE OF IOWA )
COUNTY OF JOHNSON )
ubscribed and sworn to before me by V R.lY � S Q r -)S, on this O " day of
KELLIE K. FRU HU
. comm salon Number 2218 to Public in and fort tate of Iowa
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 2,
Signature of Q�� �_
Police Chief or designee
g1/g/24
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. o
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Signatur lff City
yClerk or designee Dat s rn
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ht
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Cem/TAXIMrvenooen 92014w °a.DOC 07/2016
May.16. 2017 2:24PM
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Div of Criminal Investigation DCI Iofio. 0652
,
STATE OF IOWA
Criminal History Record Check
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Request Form
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DCI Aeeount Number: 9383 ^ FG
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be relemble, per trade of Iowa, cbspter 693.2. For towbi ilt ctiwiaal bhtory record InfotmOon, am allowed by 11w, always
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Iowa Criminal Histoa Record Chit ck Results (eel mn nilly)
M of JC' a starch of the provided name and date of birth revealed:
No Iowa Criminal Ristoty Record found wlth DCI :
❑ Iowa Criminal History Record attached, DCI #
DCI Initials 1
DCT -77 (030/10) t•'.'
Received Time May, 10, 2017 9:21AM No, 8981
C410WADOT...
SMARTER 1 SIMPLER I CUSTOMER DRIVEN wWw,lowadogov
Office of Driver Services
PO Box 9204.1 Des Moines. IA,50306A2D4
Phone: 515-244-9124 180D-532-1121 I. Fax: 515-239-1637
www.iowadoLgov
Inquiry 5/18/2017
Date:
Customer #: 4732685
Certified Abstract of Driving Record
DL/ID #: 434ZZ0578 (IA) CDL Permit Class: None
Class: D
Name: Parsons, James Samuel Audit #: 6719710
Address: 801 S 7TH AVE Issue Date: 02/23/2013
City/State: IOWA CITY, IA
Expiration 02/12/2018
Date:
Endorsements: 3
Restrictions: Corrective Lenses
Restriction None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Parsons, James Samuel DL/ID: 434ZZ0578
CDL Permit Issue None
Date:
CDL Permit
522406205
Mailing
801 S 7TH AVE
Address:
None
Mailing
IOWA CITY, IA
City/State:
522406205
Date of
2/12/1981
Birth:
None
Sex:
M
Expiration 02/12/2018
Date:
Endorsements: 3
Restrictions: Corrective Lenses
Restriction None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Parsons, James Samuel DL/ID: 434ZZ0578
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
Office of Driver Services
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status: None
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:
...: �V W,
5/18/2017
IOWA
). 0. T. `Z�
.......
EAS
Office of Driver Services
w�
Iowa Department of Transportation
Name: Parsons, James Samuel DL/ID: 434ZZ0578