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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First
1. Name
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
/C'�-,�)i;
(Office Use Only)
2. Mailing Address D06 IJ/ANA
ST lot -JA Cid /A raa.YO
3. Telephone: Home
Other:
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4. Prior experience in transportation of passengers: nose
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? AL)
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 Q
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? Y i�.S
Type of offense Where When
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8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? Ya
Type of offense Where yWhien
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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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)
derkhmidvbedg 06/2012
I reby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license nuFnber
(QO �� 3 3C7 ( . 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
STATE OF IOWA )
COUNTY OF JOHNSON )
S=ed d s orn t before me by I Y��� 1� On this –1� day of
5o)
0 4 ` CommE s�oENumb 22E81 otary Publ and for the State of Iowa
f:
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).
Signature of Police ( of or designee
Signatbre of City Clerk or designee
/tr .!O/o2
Date
9-/ / -/_2�
Date
NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names placed on the citywebsite 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
deAutaxWHn dg.pp2010.tl 06/2012
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Sep; 11. 20121 2: 55PM1
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Div of Criminal Investigation No. 3632 P. 2/2
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Iowa crippinalMat ryRecord Check Regulfq . rncln„an��
a search bifho provided name and date of birth r
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Iowa Department of Transportation
A
Office of Driver Services (follFree)900-532-1121PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
9/13/2012
DL/ID #:
960ZZ3361 (IA)
Customer #:
4120683
Name:
Ayers, Matthew Sean
Class:
D
ID Status:
None
Address:
1206 DIANA ST
Audit #:
6298560
DL Status:
VAL
Issue Date:
09/13/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
06/27/2013
CDL Cert
None
522404629
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1206 DIANA ST
Restrictions:
NONE
Restriction
None
Date of Birth:
6/27/1983
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522404629
History Information
Sanctions
Type Effective End ACD Explanation Occurrence 3UR 3UR
Suspended 10/13/2011 03/04/2012 Woo Unpaid College Loans IA IA
Name: Ayers, Matthew Sean DL/ID: 960ZZ3361
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:
"''•;`/0
9/13/2012
10 WA
D. 0. ` `
9f'I $-
BRIO
Office of Driver Services
,,,
Iowa Department of Transportation
Name: Ayers, Matthew Sean DL/ID: 960ZZ3361
9/13/2012