HomeMy WebLinkAbout12-041etl�sor��
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
1. Name
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
el -
(Office Use Only)
2. Mailing Address o k) A l e oa.
3. Telephone: Home I GI 13 G 9106( Other:
4. Prior experience in transportation of passengers: _a I I o u Ce-(-, } M 1 Cd8 C� iT wh %y S
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? )j (7
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? .J 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? i e C
Type of offense Where When
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8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? : e t
Type of offense Where When
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9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please provide the name(s)
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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)
Gark/1axi0rivbadg
09/2010
I reb certify t I issued to me by the Iowa Department of Transportation a valid Chauffeur's license'humber
7 heG y Y `�th S have 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 ApplicantDate �14�
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ZSct, JAL e> On this
F. b -7+ r a
I
C
SONDRAEFORT
Commission Number 159791
My Commission E)phs
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).
- V 6! �/�,
Signiature of Police Wf or designee
ign`ature of City Clerk or designee
Date
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
der midriv dgeapp2010d 0912010
Feb.10. 2012 12:22PM Div of Criminal Investigation
02/400/24012 Z: 11- raa.
+ DCI IO'rcn' 6911 P. 1/5
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STATE OF IOWA` -.:AI I t,� :;
Criminal History! Record Check ,
Request Form r.
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DxaMotam,Iowa 50719 ,
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T •,n rn fawn Cltmtnel Nlstnry Record Check an:
DCI Account Number 3g4 3 —rG
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Jowle %—FJ RlUkf& J1r3CUCY nca:yru 4UV-Utk acraaan (pt7lr miyl
As of a search of the provided mune and dam of blith revealed;
No Iowa Criminal History Record found with ACI ,
❑ Iowa Criminal History Record Wwhnd, DCI #
DCI initials_ & --
ICI-77 (00/25/10)
Received Time Feb. 6. 2012 12:06PM No. 2611
First Name t MlddleName
.%O
LIS, «; Gt/�
Date of Hirth
Gender r w d Social Security Number
06/ 1V / 1993
"it oFemale qg2 I S
Waive? J-0nmition. blreery recordauk sot
be releasable, per Code of Yom, Chgrier dflS For�olate Immlul AYlovy record lafarmindon, M allowed by law, Always
obtain a walver ei em me rob rd o sure he nquall,
JPaiverR!leave:tumegarepe0ntuwatherowaraesrttaaodkWmwadatatroaswfmWhWay.wrido* wlgdou-:wimoft:rl M
prwupton(oeD. Mr�Vrteryder rammnLn:reoartrnaMeYeAbrmoDl:"rnayL,deudre rlloaedty Nw,
WalverSJgftdfanl �.
Jowle %—FJ RlUkf& J1r3CUCY nca:yru 4UV-Utk acraaan (pt7lr miyl
As of a search of the provided mune and dam of blith revealed;
No Iowa Criminal History Record found with ACI ,
❑ Iowa Criminal History Record Wwhnd, DCI #
DCI initials_ & --
ICI-77 (00/25/10)
Received Time Feb. 6. 2012 12:06PM No. 2611
Iowa Department of Transportation
Office of Driver Services Roll Free) BOD -532-1121
PO Banc 9204, Des Moines, IA 5030&92114 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/14/2012
DL/ID #:
769YY8452 (IA)
Customer #:
3605007
Name:
Johnston, Zachary
Class:
D
ID Status:
VAL
William
JUR
01/06/2012
Address:
1103 HOLLYWOOD
Audit #:
4942186
DL Status:
VAL
BLVD
Issue Date:
01/11/2011
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
08/19/2013
CDL Cert
None
Suspended
522407047
Date:
IA
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1103 HOLLYWOOD
Restrictions:
Corrective Lenses
Restriction
None
BLVD
Date of Birth:
8/19/1983
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522407047
History Information
Convictions
Citation Date
Conviction Date
ACD Explanation
County
JUR
02/27/2011
04/08/2011
M14 Fall to Obey Traffic Sign/Signal
52
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date
Case Number
JUR
01/06/2012
668178
IA
Sanctions
Type
Effective End
ACD Explanation
Occurrence JUR
JUR
Suspended
09/09/2009 02/16/2010
D53 :Non -Payment of Iowa Fine
IA
IA
Suspended
07/03/2010 10/11/2010
D53 .Non -Payment of Iowa Fine
IA
IA
Name: Johnston, Zachary William DL/ID: 769YY8452
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:
so°-ep�U.....p`%Za
o'~: �.:,2/14/2012
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Office of Driver Services
Iowa Department of Transportation
Name: Johnston, Zachary William DL/ID: 769YY8452