HomeMy WebLinkAbout12-079I r
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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
Authorization Number � �_ - -k `>,
(Office Use Only)
APPLICATION F PEDICAB DRIVER
(Police Department r '
between 8 a.m. to 3 p.m., Monday - Friday.)
First
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Middle
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Last
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1. Name w
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2. Mailing Address ` 9 Al o 2 ^ _ ` / (A
3. Telephone: Home '' / ?
Other:
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4. Prior experience in transportation of passengers:
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? N d
Type of offense
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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?
Type of Offense
A/ J
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
9. Have you ever applied to bean 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)
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I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number"-.
0 1 7 /�) -',, 7 z . 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)
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Signature of Applicant Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
MSubscribed and sworn to before me by �ii�, Q , C- �� �\ On this 1 day of
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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).
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S' natur of Police Chief or designee
S gn9ture of City Clerk or designee
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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
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Mar. 9. 2012 2:24PM
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Received Time'Mai, 6. 2012 1:30PM No -0837
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Iowa Department of Transportation
Office of Driver Services (Tali Free) BOE -532-1121
PO Box 9204, Des Moines, IA 503116-9204 515-244-9124
FAX: 515-239-1837
Inquiry Date:
3/21/2012
Name:
Steele, Matthew
CDL Cert Status:
DeClalrmont
Address:
429 N GOVERNOR ST
City/State: IOWA CITY, IA 522453032
Mailing Address: 429 N GOVERNOR ST
Mailing City/State: IOWA CITY, IA 522453032
Certified Abstract of Driving Record
DL/ID #: -013681492 (IA)
Class: C
Audit #: 4352249
Issue Date: 05/14/2010
Expiration Date: 01/22/2015
Endorsements: NONE
Restrictlons: Corrective Lenses
Date of Birth: 1/22/1980
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Steele, Matthew DeClalrmont DL/ID: 013BB1492
Customer #: 4206845
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
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:
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IOWA :>,
3/21/2012
D. 0. T.
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Office of Driver Services
Iowa Department of Transportation
Name: Steele, Matthew DeClalrmont DL/ID: 013BB1492