HomeMy WebLinkAbout12-102� r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240- &265//I
356-50 t
(3 19) 356-5497 FAX
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
First Middle Last
1. Name —f
2. Mailing Address
3. Telephone: Home
Other: 3/y'67/ /S8S
4. Prior experience in transportation of passengers: I Pr K/&a✓CAG
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? A
Type of offense Where When
II— /a J_
(Office Use Only)
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? .,VO
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 5
Type of offense Where When
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8. Has your drivers license or chauffeurs license been suspended or revoked in the last five years? 2v
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)
4,0
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND'_§jATE 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)
cierWt dmbadg 09/2010
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hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
_d sSPVcy9N,/ . 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) /
Z
Signature of Applicant Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by `�� �T7Y� Gy/��sr$ On this /�� day of
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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).
Sign t re of Pa Chief or designee
Signat'are of City Clerk or designee
;r-is=/a
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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V C Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
5/8/2012
DL/ID #:
255DD4944 (IA)
Customer #:
4329777
Name:
Williams, Clifford
Class:
D
ID Status:
None
Steven
Address:
2430 MUSCATINE AVE
Audit #:
5785161
DL Status:
VAL
APT 8
Issue Date:
02/07/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
01/04/2017
CDL Cert
None
522406649
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
2430 MUSCATINE AVE
Restrictions:
NONE
Restriction
None
APT 8
Date of Birth:
1/4/1980
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522406649
History Information
Convictions
Citation Date Conviction Date ACD Explanation County IUR _
02/22/2012 103/20/2012 .M14 Fail to Obey Trafflc_Sign/Slgnal X52 ISA_'
03/06/2012 '04/11/2012 ;B64 ,No Insurance Card 52 IA
Name: Williams, Clifford Steven DL/ID: 255DD4944
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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5/8/2012
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Office Driver Services
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of
Iowa Department of Transportation
Name: Williams, Clifford Steven DL/ID: 255DD4944
May.14. 2012 3:46PM Div of Criminal Investigation
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