HomeMy WebLinkAbout12-089r Authorization Number Va- -x 7
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110
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APPLICATION FO PEDICAB D IVER
CITY OF IOWA CITY (Police Department r iew mus a made
410 East Washington street between 8 a.m. to 3 p.m., ay y— day.)
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name I-CyI( I f C 1 IV V r)V) I--
2. Mailing Address 10 12- C D Aq Q f
3. Telephone: Home 3(o3-G-j(,'(Dc(0t�) Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? i') 0
Type of offense Where When
B. 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 Where When
7. Have you been convicted of any traffic offenses in the last five years? �JfP
Type of offense Where When
l2- a"d I o 2001 avtd 2001
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? V)
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)
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1 hereby certify that I have issued to me by the Iowa Department of Transportation a valid G4auffQu s license number"
b� �tA 0^l 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
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STATE OF IOWA )
COUNTY OF JOHNSON ) //1 r I
S scribed nd sworn to before me by AVS �� CD ke-,, On this 1 2-4_�' day of
AKELLIE K. TUTTLE
mm 'J�n Number ntlle ary Public in and for the State of Iowa
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).
Signat re of Police Chief or designee
SigMature of City Clerk or designee
Ll if
7-16, z
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
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nal 01t10Wd 11�ty
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(Crimingtogtory Record Check
Request Form
To; 1o�YaAfyistoriOfCr:YnianlShWesttgAttou
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216 E, P Street
besrY�olgev,Totiva 50319
(915) 939.6066
(615) 725-6080 R'nx
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asearc]ioftheprovidedname anddtjfaaEbitth-revealed:
No Towa a-Im n d Vistory Record found with)) CT = ,
Q Xowa C`ta'mfns1 istoq Record areaehed, ))O1 #
bGruliCials�-_ '
Re�oi�a,�•1'imw•��: d 1011 11.OAPM Nn RdR7
Iowa Department of Transportation
Office of Driver Services (Toll Free) 8M-532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Inquiry Date: 4/12/2012
Name: Cohen, Andrea Naomi
Address: 1012 COTTONWOOD AVE
City/State: IOWA CIN, IA 522402111
Mailing Address: 1012 COTTONWOOD AVE
Mailing City/State: IOWA CITY, IA 522402111
Convictions
Certified Abstract of Driving Record
DL/ID #:
OOSAA0019 (IA)
Class:
C
Audit #:
5837912
Issue Date:
03/06/2012
Expiration Date:
06/18/2017
Endorsements:
NONE
Restrictions:
NONE
Date of Birth:
6/18/1989
Sex:
F
History Information
Customer #:
4460649
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD Explanation County IUR
..,.,.... _ _ .-___....____... _ _._ _ _.. _ ..
0_7/26/2007 ;08/29/2007 _ S93 Speed ` IL
09/06/2009 _10/07/2009 IS92 .Speed 44 IA
Name: Cohen, Andrea Naomi DL/ID: 005AA0019
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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4/12/2012,
IO0. WA
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Office of Driver Services
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Iowa Department of Transportation
Name: Cohen, Andrea Naomi DL/ID: OOSAA0019