HomeMy WebLinkAbout12-088t 1 r i
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CITY OF IOWA CITY
410 East Washington Street
�_ ewa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name
2. Mailing Address 2-13 C
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
►;
eA_1
(Office Use Only)
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3. Telephone: Home(y z Z 3 `(v (� Other: 7(,7 you-, / b b G
4. Prior experience, in transportation of passengers:
5. Have you ever been convicted of ahyYhisdemeanors and/or felonies in this State or elsewhere?�
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Type of offense 9
When
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6. Have you be 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? Iy
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? LI/o
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)
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)
clerM=idnvbadg 0912010
I hereby certify that J have i sued to me by the Iowa Department of Transportation a valid Chauffeurs license number
� 4f � C (� .S^ 2 . 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) r
v
Signature of Applicant Date / ( � / i Z
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by S On this �� day of
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).
gn�of Police f or designee
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Signa re 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.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
u�*na wa zoio.doc 0912010
Iowa Department of Transportation
Office of Driver Services (Tai Free) 800-532-1121
PO Box 9204, Des Manes, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Inquiry Date: 4/6/2012
Name: Childers, Skyler Adam
Address: 213 4TH ST E
City/State: NEWHALL, IA 523159715
Mailing Address: PO BOX 391
Mailing City/State: NEWHALL, IA 523150391
Name: Childers, Skyler Adam DL/ID: 343AE6528
Certified Abstract of Driving Record
DL/ID #; 343AE6528 (IA)
Class: D
Audit #: 5526677
Issue Date: 09/22/2011
Expiration Date: 06/19/2014
Endorsements: 31-
Restrictions:
LRestrictions: NONE
Date of Birth: 6/19/1978
Sex: M
History Information
CLEAR DRIVING RECORD
Customer #:
2860365
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, 1, 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
•IOWA •'¢''s,
4/6/2012
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Office of Driver Services
Iowa Department of Transportation
Name: Childers, Skyler Adam DL/ID: 343AE6528
Apr. 12. 2012 12:OOPM Div of Criminal Investigation No.4379 P. 3/6
1frEo'dN WV91:01 il0i '01 'ldv W1 Paniaaay
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STATE OF IOWA
Criminal History Record Check -
Request Form
To: Iowa Division of Crimiml lovealaalloo
Support Operitloar Borne, 0 Floor
11.5 L 70SIMI,
DmMolop,iowt 50319
(515) 7SS•f066
(515)V340110 ;FAR
DG Account Number: 3
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From: MAMAS I aXL
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Otis a.6, I k E;,WO
Phase., .(31A) 33P- mq.
Fear . - 3111 351- -1
•MAI . Yw. !M MI •vvV v.uu...w.m.v.
Lint Name m.,dm
.v. v.�_____._.
First Name lmanda
Mild Le Name race
C Inii�e�
Sk ler
aw.
bato of Birth meeab
Gender aMadea
Social Security Number
No Iowa Criminal History Record tbund with DCI
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)IMale ❑Female
❑ Iowa Cominal History Accord altmohed, DCI a
WdrVer/n%rmddkn: Wuheutarlptedw■lver from the rnb)ecloftberequest, a complete eHminetabtary record m■yaot
be relmmble, per Coda of Iowa, Cbepter OLM For complete criminal binary record information, at Allowed by l avr, always
obbin awaiver, sl atorerramlbesubedurabe uest.
WOIV,*r A?eleoSo; IAaRbyaha peooivbn for Ne abne roQuatins off; W m cmdW=rove y1mIW pygry wood chick Wm ee Di.ieimorCNninl
r,nglpfon (DCI). AW aimlut huTmy dab rmannina eA eyl 6 mri,uained by do DCI may bo alamd V anawrd by taw.
Wahersignarnrr.
Iowa Criminal History Record Cheek Results
(oG mo aaty)
As of y e search oPthe provided name and date of birth revealed:
No Iowa Criminal History Record tbund with DCI
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❑ Iowa Cominal History Accord altmohed, DCI a
w;.... CD
DCI initials
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