HomeMy WebLinkAbout17-159f
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. J —? —1 t�q
(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 "repuired" information will result in denial of the application
3. Contact Information (REQUIRED) Email: Yrt bo 2(LA.�mi/ coat Cell e: �9-3�31KO
(All written communication sent via email)
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4a. Driver's License expiration date (REQL
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
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6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? ho
Tvoe 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? no
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? h O
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro M1e the r>Jle(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT M- R- TftD •Z4;
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE F RE IEvfl
You must apply for an individual Department of Criminal Investigation Report (form avAl)a5le n re&At).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
1130 WIVE= issued on 10-29 (Y- expiring on /a- (8'20 1 understand that if
falsely answer any questions in this application, that this application may be denied. I agree that in making this application,
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 Wptary Public)
Signature of Applicant ZJ%pJ �uu�n(�pq�nsw dA Date-30'� M
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(51 �I
STATE OF IOWA ) v
COUNTY OF JOHNSON )
Subscribed and sworn to before me by X12 iS u . . �4 Su au 5 &e A� on this 'Alf day of
I have reviewed this application, DCI report, and the State certified driving record of this applicant and
there is no information which would indicate that the issuance would be detrimental to the safety l
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
R determined that
N-weifar" resi-
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ca
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.
rye G
ig ature of City Cleg or designee � D to
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
a&*JTAXIDRN9ADCEAPPL92014a�ae.DDC 07/2016
11M. LO. Lull [:4inn uiv oI i,riminai Investigation No. 1166 N. 1/1
Cl o, .. �/,�,�� ar. ......i 11/27/2017 11:4. n20Y 1 .Vu2/002
STATE OF IOWA
Criminal History Recaird Check
Request Form
To: Iowa Division of Criminal Investigation
Support Operations Bureau, is, Floor
21S 11, 7'h Street
Des Moines, Iowa 50319
(515) 725-6066
(915) 725.6080 Bax
DCI Accouil t Number:
From: Cit oflowaCit
City CIelk s Office
410 r, Washington Street
lows Cil , IA 522.40 0
Phone: 319,356-5041��
Fax: 319,356-5497
1 mu re uestin an Iowa Criminal Histo Record Check on:
Lost Nepte (Mandatory)
/
TJ
r s (�
First Nalrle mmoidato )
Mjddle
Rix s in u s -s Le" rpp
W,
V-
A(lur(
Date of Birth mendalory Gender mandelory)
!4C'o
Social seen ri
Number recommended
ITBMale ❑Female
K 8S— q0-
Cif 71
Wit Iver 'Worntnrion: Without a signed waiver Rom the subject of the request, a complete criminal history record may not
releasable, per Code of Iowa, Chapter 692.2. For c�10nlete
Ob eriminal history record
obtain a waiver sf eture from the suD act of rho r Crest
information, as allowed
by law, always
Waver Release: i hueby give pem istion for the "bore Muenidg official to conduct m Ie1w Criminal hlslory record check w Ih Iheptvision of Qimin"1
Invesfigrtion(DCO. My uimind history daiaconcemin me
B t"I is mabaained by the DCI may be seinttd
u allorvod
by law,
Waiver Signature:
Io%weal Criminal Histo Record Check Results
AS I I ' I �'
Of ' B� a a search of the provided name and date of birth reveal
CA—
No
No Iowa Criminal History Record found with DCIS
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Iowa Criminal History Record attached, DCI k
w
17CI initials O�
DCI -77 (08/25/10)
Received Time Nov.21. 2017 10:16AM No, 0540
Iowa Department of Transportation
Pursuant to Iowa Code 4321.10, 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.
OLRce ar DrN�er Services (I dl t Ieci 804532 1121
PO Box 92D4, Des Mantes, IA 503D69244 515-2449124
Fi►�
5152391931
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Certified Abstract of Driving Record
Inquiry Date: 11/27/2017 DL/ID #: 430W W8558 (IA) Customer #: X13168
Name: Rasmussen, Perry Class: D ID Status: ���1� �
Allan �-�"'r.' �
Address: 414 Pleasant St Audit #: 8571396 DL Status: ;NICE
Issue Date: 10/29/2014 CDL Status: 1Jone �r
City/State: Iowa City, IA 52245 Expiration Date: 12/18/2022 CDL Cert Status: None
Endorsements: Chauffeur 3 CDL Med Status: None
Mailing Address: 414 Pleasant St Restrictions: NONE Restriction Non�i
Supplement:
Date of Birth: 12/18/1960 C) --r
Mailing Iowa City, IA 52245 Sex: M O
City/State:
History Information ��
7G �•�I
CLEAR DRIVING RECORD C:) � V
;r
Name: Rasmussen, Perry
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:
.. 11/27/2017
�.......
IOWA.
D. 0. T Pf
i JIM, Office of Driver Services
Iowa Department of Transporation
Name: Rasmussen, Perry Allan DL/ID: 430WW8558
Allan DL/ID: 430WW6558
�
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:
.. 11/27/2017
�.......
IOWA.
D. 0. T Pf
i JIM, Office of Driver Services
Iowa Department of Transporation
Name: Rasmussen, Perry Allan DL/ID: 430WW8558