HomeMy WebLinkAbout12-159K.
CITY OF IOWA CITY
410 East Washington Street
Iowa Cit Ljowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
1. Name
2. Mailing Address
3. Telephone: Home(319)-338-
4. Prior experience in transportation
Authorization Number \--), " 1 S I
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Last
Other: (3140-512-90
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? N U
Type of offense
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?N r)_
Type of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
r- 1.
Where
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? t4n
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)
de"iarivbaeg 09/2010
I hereby certi I h ve issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
7 &oql ��� � � 3 . 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) "10
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON ) -
subscribed and swom to before me by �hoh F 9 ��wnr� Cle oty\ .. On this \� day of
..� a o c � !7�
_ ��lot� a in and fort the State of Iowa
*R#41R44Yt##4###*#***R#R#*RRfifkffY#i#Y#*********t*fA[[41f[11k4[1k*4*f**!*#R*##Rf R4R##Rt####kif#4fM11!!11l1l414*[f****k**Ri*i#fk##kk#!!4!41!![1
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).
Signa re of Pol a hief or designee
Sfgnatbfe of City Clerk or designeLy
Date
Date
NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names placed on the city website at
icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved applicationy
DCI report v
State certified driving record
Website update
d«wiaadmbadgw,OM. 09/2010
Aug.
9.
2012
4:17PM
Div
of Criminal Investigation
No.8240
P. 2/30
Aug.
6.
2012
10:19AM
City
Clerk — City of Iowa City
No. 2617
P. 2
To: Iowa Divlslon of Criminal Tnvestigatlon
Support Operations Bureau, VFloor
215 E. 7h Street
Des Moines, Iowa 50319
(515) 725-6066 .
(515) 725-6080 Fax
Check
(2aa
DOIAccount Number: A/boX —F—
(if applicable)
F`(inapplicable)
From: CITYOEIOWA.CITY
CITY CT kRIC'S OFFICE
410 E. wASMWGTOM STREET
IOWA CITY IOWA 52240
Phone; 319356.5041
Pax: 319356.9497
Ec)w,arcJ
walverInjorinallon: without a signed waiver tlroln the subject of the request, a complete criminal history record may not
be releasable, per Code of lower Chapter 692.2. For late criminal history record information, as allowed by late, always
obtain a wa lver kianetul'a from thn mrh iprF n£Fho renuncF.
WdiYBY,RC1gaS6: lhereby give pennlrclon for did above regocsdnS odlold ro conduct an Sown criminal hisioryrecord dmckwhh the
1nvestlgation(DCO, any criminal hslorydete concemlegnte lAatlsmelnlelned by the))CI may bcrcicase4 as nlfyltied bylaty. ,
IOOWaCriminal History -Record Check Resulfe
As of—F— — -t /�- I d� & searoh of the provided name and date of birth xavealed:
1 No Iowa Criminal Mstory Record found with DCI
Iowa Criminal Mstoxy Record attached, DCI #
DClinitia14
tArp;vpI Tlmpi'Allp 6 irlAll 10.90AM bl„ h991
of Criminal
(QTIu�o,paly)
�
li
,L� CJ
r.•xr
`o
in -T1
Iowa Department of Transportation
Office of Driver Services (Toll Free) WO -532-1121
PO Box 9204, Des Marines, IA 503WQ204 515-244-9127
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/8/2012 DL/ID #:
769YY6103 (IA)
Name:
Heath, Thomas Edward Class:
D
Address:
2801 HIGHWAY 6 E LOT 394 Audit #:
6044993
None
Issue Date:
06/13/2012
City/State:
IOWA CITY, IA 522402658 Expiration Date:
05/19/2017
.Speed
Endorsements:
3
Mailing Address:
2801 HIGHWAY 6 E LOT 394 Restrictions:
NONE
Date of Birth:
5/19/1959
Mailing City/State: IOWA CITY, IA 522402658 Sex: M
History Information
Convictions
Customer #:
915880
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
.Speed
Citation Date
Conviction Date
ACD
Explanation
County
IUR
10/07/2006
10/31/2006
B61
Violation of Accident Requirements
52
IA
12/14/2007
12/27/2007
S92
.Speed
52
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number 3UR
09/19/2011 ;648797 'IA
Name: Heath, Thomas Edward DL/ID: 769YY6103
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:
•2:`a/p'4,
8/8/2012
IOWA y''
*0.
D. 0.T
'S
1
F BAIYEA =
Office of Driver Services
Iowa Department of Transportation
Name: Heath, Thomas Edward DL/ID: 769YY6103