HomeMy WebLinkAbout12-002I �r
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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
2. Mailing
Authorization Number
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
3. Telephone: Home Other: 3lti' SqI-5ZIX
4. Prior experience in transportation of passengers: Iq do.'s ask 'I"a' " `�, Zowl c1b
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Alo
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? AID
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? �es
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? tyj
Tvoe 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) 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)
clerWYaxitlnvbatlg
09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
LE/ W W-+-415 S . I understand that if I falsely answer any questions in this application, 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)
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by J LCS 4 r"1 gkt k i n C S On this S� day of
Notary Public in and for the State of low �-
---s 221819
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).
Signaftfre of Police C ' or designee
Signdture�o City Clerk or designee
/- 5 -1,52-
/
,52-
/— 4% `/J_�
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.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
derW idnvbadgea,201 o.doc 09/2010
Iowa Department
Office of driver Services
PO Box 9204, Des Maines, IA 503015-92134
Inquiry Date: 1/5/2012
Name: Haines, Justin Michael
Christopher
Address: 115 1/2 S Dubuque St #4
City/State: Iowa City, IA 52240
Mailing Address: 115 1/2 S Dubuque St #4
Mailing City/State: Iowa City, IA 52240
Convictions
of Transportation
(Toil Free) WO -532-1121
515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
DL/ID #: ISIWW7795 (IA)
Class: D
Audit #:
3676753
Issue Date:
09/08/2009
Expiration Date:
08/30/2014
Endorsements:
3
Restrictions:
NONE
Date of Birth:
8/30/1978
Sex:
M
History Information
Customer #: 4537113
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
of
Citation Date Conviction Date ACD Explanation County JUR
08/27/2011 09/27/2011 M14 Fail to Obey Traffic Sign/Signal 52 IA
Name: Haines, Justin Michael Christopher DL/ID: 151WW7795
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:
............ '4
1/5/2012
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Office Driver Services
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Iowa Department of Transportation
Name: Haines, Justin Michael Christopher DL/ID: 151WW7795
12,DeC. 16._ 20115 3:16PM Div of Criminal Investigation
i DCI Iolm 3656
STATE OF IOWA
Criminal History Record Check
Request Form
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be reIntsb1%per Cone orlern. Chapter 692,2. For mfr odmbut bbtory Mord laror=tion, u a0owed by law, ahrays
obtain a Wither 008tan 4om Ike sob cot afthe Munt.
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As of a a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI ,
✓✓✓❑ ' Iowa Criminal History Record allmbA ba N
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Received Time Dec. 9, 2011 12:09PM No.5802