HomeMy WebLinkAbout12-001MIIr®ill
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
.4, -
Authorization Number "-= O
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
First
(Office Use Only)
Middle Last
1. Name on„kl K I�Lok£Nc�
2. Mailing Address �/�l C2DSS Pka-I- Avg #-- / -C,
3. Telephone: Home Other:
4. Prior experience1%n Ltra�nsportation of passengers: /SFA" - C � 1 r,, SL
�TD I E( EA, ri/,,- 0 Full G E. y 6-x/15
--SII Mff-, l.,- ivj , C_ 5-V"I S
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? NO
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? N O
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? N
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)
N�
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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
deMnaxianv�adg 09/2010
hereb`��certify�}h 1 have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number.
W S /'T 99'Dr/ 1 understand that if I falsely answer anv auestions in this aoolication. that this
application may be denied: I understand that if I falsely answer any of the questions in this application, that this application will
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 a license
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) /n
Signature of ApplicantVYL Date 11431 / —z—
STATE
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by On this 3' _ day of
in and for the State
l i s11`i
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I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
SigrAfure of I' eeief ordesignee
Sign uru�ty Clerk or designeez�j
Date 7
Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
.tan .,dnw ,.p,201 0 d. 09/2010
Jan. 4. 2012 9:22AM Div of Criminal Investigation No.4964 Y. 1/1
C `LL 'I -I UL:MP r ouow Cab or lows uay 319.338.27.08 p.1
f STATE OF IOWA
1 Criminal History Record Check
Request Form
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215 E. 7i' Sl rcpt
D.s )loin., lam, Mi 19
(51j) 725-6066
(S(5) 725.6080 has '
1 Inn icnnstin!,, n Lawn CrimimiI I1i31mi Record Check ml!
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Phone: AA) 33b - q- )')
rav: 11 21-1- 73-L
Last Name wmunaivr,I
Fitw Name Im;o,rmav)
Middle Name bccam,ncndrdl
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Date of Birth walAnorv,
Cisnr(L•P Im.uJmnrv)
Social Security Nuumber rkomm awl
�95
Male ❑Female
J/ysCO �e)9�SV
Waiver hybroldlion: withow n signed waiver hrm the subject of Ibe rcquesl, a complete criminal history record nay not
bn re tensa lilt, prr Code of 1u11•a, Clntwor 692.2. For eg noINa criminal history record in rormnlion, as allowed by Inw, nlwnys
obtain to wnirt•r sienxf(it Prom Ihr. sabicrt of the rel uest. '
Waiver ReferLr'elh,:raLl vin•pcmnsi,m liV na•uhorr IunungollimI m contact rrl lava clirnu-al Maury Ward cluck with the Divlston orchminm
Imnligswa lnt'hAny+nminallama, a ni:nmvnl ngn Iilx nwtNoin• 'lar lk'l may emltnecdns olloa,d6w law.
lown1 Criminal History Record Check Results
As 119'__ I — M �seurcll orthc provided name and date of birth revealed:
iNo Iowa Criminal Ilislop' Record found with M
❑ Iowa Criminal I li3lory Record nuaoked, DCI it
I)Cl
10)
Received Time Dec.12. 2011 2:05PM No. 4028
(DCI aw udy)
ARTS
Page 1 of 1
Iowa Department of Transportation
Office of Driver Services (Tall Free) 800-532-1121
PO Box 9204, Des Manes, IA 50306-9204 515-244-9124
%&I FAX 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
12/22/2011
DL/ID #:
568AG9104 (IA)
Name:
Florence, Ronald
Class:
D
Herschel
rf'96—Y
Office of Driver Services
Address:
801 CROSS PARK AVE
Audit #:
5699738
APT 1C
Issue Date:
12/22/2011
City/State:
IOWA CITY, IA
Expiration
09/27/2016
522404491
Date:
Endorsements:
3
Mailing Address:
801 CROSS PARK AVE
Restrictions:
Corrective Lenses
APT 1C
Date of Birth:
9/27/1953
Mailing City/State: IOWA CITY, IA
Sex:
M
522404491
History Information
CLEAR DRIVING RECORD
Name: Florence, Ronald Herschel DL/ID: 568AG9104
Customer #: 5783128
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert None
Status:
CDL Med None
Status:
Restriction None
Supplement:
Pursuant to Iowa Code §321.10, I, Kim Snook, 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:
••""••: '#
':.
12/22/2011
IOWA
l/.
rf'96—Y
Office of Driver Services
Iowa Department of Transportation
Name: Florence, Ronald Herschel DL/ID: 568AG9104
http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 12/22/2011