HomeMy WebLinkAbout12-097Authorization Number 1
r 1 (Office Use Only)
APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
41 0 East Washington Street between 8 a.m. to 3 p.m., Monday — Friday.)
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First Middle Last
1. Name C-4k-'S 4e4�er C/9 %rs UQ r o,
2. Mailing Address /i � r) %% Sl,. tf
3. Telephone: Home 0Y6,,7, Other:
4. Prior experience in transportation of passengers: /U ,, e Q. s �gx `- r_ a c(,
i
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /1/0
Type of offense Where When
6. Have youonvicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? b e c
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? AIV
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? Nrr
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)
derM.,dni .dg 09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
005- tn/L✓ `,9 36 . 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 J Date r13 -1019-
STATE
/9-
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by C� C;S4 aL "✓ �erga On this day of
SONDRAE FORT
Commission
791
Mv CommisssNumber .I�. 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).
SSii 4yl,ature of Polic6oChief or designee
A.I.t/
Sign tureo 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
dedNa dnr dgeaW2010d 09/2010
Aur 12. 2012 12:OOPM
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Div of Criminal Investigation No.4319 P. 1/6
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STATE OF IOWA
Criminal History Record Check =
Request Form
DClAccoumNumber. 4313
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support operanonn Bureau, 10 Floor ,
21sL.70street 5kbvtr.s Qr•
Me Molnee, Iowa 603196-a y o(919) 726-6066 IQ -of,
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LastName madato Fire! Meme malmloiy)
Middle Name ,eoom
As of a search of the provided name and date of birth revealed:
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Date of Bt -(mm",Y) (leader mud, a
Social Security Number ,
.�
NQ Iowa Criminal History Record found with DCI
U y .3U / s' l &1. Qaemate
`/75' - 6 y_ 8 79-. Y
Walver14royrnatlon., Without a elpedvalver from the eub)eelortbe request, a complete criminal bletoryrecord may not
be relumble, per Code of lows, Chapter 6912. For 1plholate crbalud hblory record Information, wa allowed by law, dwayr
obtain a wnt"YolimeturefromThesubeetofthe r1quest.
Waiver Nolease.1bacbyedKpmWUMformeaburarMwinraMWwwoAtclBelowuimkwlbiwgy rdchakwMNenivblanefedmhrl
In.milrpbntad). AnycdminAklnmdamcaeeednaneiburmeW w4bydo DCImerbemIMWualouedbydW,
Waiver Signature.
Iowa Crimi11al 1111-itory Record Check Results
(Damurdy)
As of a search of the provided name and date of birth revealed:
c N
.�
NQ Iowa Criminal History Record found with DCI
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❑ Iowa Criminal historyRecord attached, DCI #
_
DCI initials—&01
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a
Iowa Department of Transportation
ILA Office of Driver seivices (roll Free) 800-632 1121
PO Box 9204, Des Moines, Ut 5030E-9204 515-244-9124
140 FAX: 615-239-1837
Certified Abstract of Driving Record
Inquiry Date:
5/3/2012
DL/ID #:
005WW9836 (IA)
Customer #:
4138394
Name:
Bergen, Christopher
Class:
D
ID Status:
None
Charles
Address:
1920 H St
Audit #:
3260164
DL Status:
VAL
Issue Date:
04/29/2009
CDL Status;
None
City/State:
Iowa City, IA 52240
Expiration
04/30/2014
CDL Cert
None
Date:
Status: -
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1920 H St
Restrictions:
NONE
Restriction
None
Date of Birth:
4/30/1965
Supplement:
Mailing City/State:
Iowa City, IA 52240
Sex:
M
History Information
Convictions
Citation Date C ..... .. ..__.__ . __ ._._. __.._._
09/12/2009 .10/07/2009 !F04 Seat Belt Violation 52 IA
Name: Bergen, Christopher Charles DL/ID: 005WW9836
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:
;:......:;1/°h
5/3/2012
IOWA`4°4
p
D. 0. T..
f OBIYER S,=/
Office of Driver Services
Iowa Department of Transportation
Name; Bergen, Christopher Charles DL/ID: 005WW9836