HomeMy WebLinkAbout12-027� r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319)356-5497 FAX
1. Name
2. Mailing
3. Teleph
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.)
4. Prior experience in transportation of passengers:
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 n convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? A10
Type of offense Where When
9. Hgve you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
D
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)
deWt.!&d badg 09/2010
I her yy r that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numbed
IL/ �� 2 1 71!q7 . 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 prov�s of Title Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature ofApplican Date��/
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STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by «c. lis' ReV 6 On this day of
>a�
SONDR'
°. Commission Number 759791 fr""
Mygommissbn FIeB Notary Public in and for the State of Iowa
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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).
Signatur of Police Chief or designee
ig t�oi
City Clerk or designee
Z -f-/ z
Date
02 / 02
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
deMm drIwadeaappzm°d« 09/2010
Iowa Department of Transportation
Office of Driver Sentices (Toll Free) 800-632-4121
PO Bax 9204, Des Moines, IA 50306-92134 545-244-9124
FAX: 515-239-1837
Inquiry Date: 2/8/2012
Name: Rayburn, Charles William
Address: 4289 MAUREEN TER
City/State: IOWA CITY, IA 522409200
Mailing Address: 4289 MAUREEN TER
Mailing City/State: IOWA CITY, IA 522409200
Convictions
Certified Abstract of Driving Record
DL/ID #: 49OXX7744 (IA)
Class: D
Audit #: 5756590
Issue Date: 01/24/2012
Expiration Date: 11/11/2014
Endorsements: 3
Restrictions: NONE
Date of Birth: 11/11/1983
Sex: M
History Information
Customer #:
1198530
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Improper. Registration
Citation Date
Conviction Date
ACD
Explanation
County
3UR
09/05/2008
'12/10/2008
,M57
`Fail to Yield Half of Roadway
82
'IA ,
02/04/2009
02/18/2009 __
.,_
Improper. Registration
_ 16
IA
._ /2009
06/09
,06/25/2009
F04
Seat Belt Violation ,.__. ,
w. _.. ,82«,
SA ,
04/21/2011
-05/18/2011
F04
Seat Belt Violation
.52
:IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
07/08/2008 ,449643 _ IIA
Name: Reyburn, Charles William DL/ID: 490XX7744
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:
:1X,l; 4r
2/8/2012
IOWA .
D. 0. T.
Office Driver Services
7p'•••••" S_=
of
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Iowa Department of Transportation
Name: Rayburn, Charles William DL/ID: 490XX7744
Feb. 6.
2012.
3:16PM
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Received Time Jan.30. 2012 9:39AM No.1456