HomeMy WebLinkAbout12-235rr ,
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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
Authorization Number. la -MJ5
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
(Office Use Only)
First Middle Last
1. Name E)AV iD 1362T -Fit S,SEL�
2. Mailing Address NO' k1 `rj N Ay (, L-0 [ 2 2 Togs q- cl 7X �2 2 (fo
3. Telephone: Home Other:
4. Prior experience in transportation of passengers: yd
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
Mo
6. 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
rZ o
7. Have you been convicted of any traffic offenses in the last five years? YE -5,
Type of offense Where When
SPaz/KC XZ owA CI Ty t 2 3 . Z810
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense Where When
VO
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)
dennexi0rrvbatlg 09/2012
I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeur's license 'umber
LSA f� D �i6 . I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that if 1 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 provisi f 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_tdbed pd sworn to before me by Da J I' 0t FU S� � � On this � (' —day of
s.Q_ KELLI€ K. TUTRE e„ Notary Public in and for the State of Iowa
My
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).
g8f nature o Police Chief or designee
9'? 7'/ z
Date
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
Signature of City Clerk or designee
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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tOW6 Cilminal 11iatoiyRecord attached, MIX*
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J)CI.7.1 MA12.61101
Received Time Sep. 14. 2012 3:47PM No.3295
Iowa Department of Transportation
Office of Driver Services (fol Free) SM -532-1121
PO Bac 9204, Des Moines; lA 5O306-92Od 515-244-9124
FAX 515-2391837
Inquiry Date: 6/6/2012
Name: Fussell, David Robert
Address: 732 MICHAEL ST APT 9
City/State: IOWA CITY, IA 522465520
Mailing Address: 732 MICHAEL ST APT 9
Mailing City/State: IOWA CITY, IA 522465520
Convictions
Certified Abstract of Driving Record
DL/ID #: 255DD9633 (IA)
Class: C
Audit #: 1679905
Issue Date: 11/29/2007
Expiration Date: 11/06/2012
Endorsements: NONE
Restrictions: NONE
Date of Birth: 11/6/1955
Sex: M
History Information
Customer #:
4652860
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 3UR
05/07/2009 05/11/2009 i =Speed_(SO.mph & under In 35-55 mph. zone) I48 _ _ _ _ _IIA___ _
._........__... __...__...._......_....._.W__.._._._...___...__._.—.__s..............._. �_._
11/24/2010 12/03/2010 j592 ;Speed (SO mph &under In 35-55 mph zone) 52 i1AJ
Name: Fussell, David Robert DL/ID: 255DD9633
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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6/6/2012
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Office of Driver Services
Iowa Department of Transportation
Name: Fussell, David Robert DL/ID: 255DD9633