HomeMy WebLinkAbout12-264� r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name
Authorization Number \`1-1-I)lA
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
2. Mailing Address a 3e27 c, coclA I $] SO(,/A cz%'% �
3. Telephone: Home 3)% s -3,2 0,5r Other:
4. Prior experience in transportation of passengers: XEAA5 fz�� OC -)7 a �2
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? �J
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�,?
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
8. Has your drivel's license or chauffeur's license been suspended or revoked in the last five years?
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)
AJ-(-,)
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)
derby drivb dg 09/2012
I
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
l Z2 10;5 . 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 time ith 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 )
�5
Subscribed and sworn to beforeme by t�' o� �r On this day of
Nbtant
Publicin and for the State of Iowa
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).
fr
!EfignaturV& Police Chief or designee
—/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.
Signa ure of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
// %"/02
Date
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STATE OF 111WA
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Criminal History Record Checks
Requat Form
To: IOWK Dlrk(on ofCrbnlnst lnvasliyat(oo
Support Operations Bureau, I" Floor
115 E. Th Srtet(
Drs Moiau, Iowa 50319
(51s) 725-6066
.(SIS) 715.6080 Fex
1 em re uesiing an Iowa criminal history Record Check on:
DCT Acconnt Numhtf: 9967-F
prnrpllnwr
Prom; Yellow C.b or loaea Ciry
P.O. Dos 928
%IYa City, U. 5229.9
(. 9) 338-9777
Phonc
Farr (3][9)339-7302
Last Dame tmra/a oryl Firsthaaraa (mure.mni Middle N3(nc I.., a aedj
1) ate ofBirth (m.ns.,m)
I Gevderj See[ fll-SCCRAtyNasubc[Gmarrrwm
alYe1'fhforema(low Without a signed wolvtr rrom the subject orthe request, a complete erinlblal hlstnry record rnal• out
be releasable, prr Code DUMB, Chsprer 692.2. For comnle(r rrimival hfttoq'•mtard information, 21 g1lowed by lett•, Oways
obta(o a walver it oeturs from the suh acr.of there uest.
Ma(vtr.Refcase; l releby 6"n pamisalm rot Vlv abnK q^'I ng afdcla)t1 uMQun amore aimiml aisto:yrecord cbeJ: with me Dkifior ofCrimiml
'Imesriaalion(D:1). �N)-ofimtnllNnolydgtataitcm 01 Cs 1115 .Incd6ythe oci may 611 wilbad as showed by ran.
IN(verSTgaatrrre Y
lowa^Criminsl History Record CheekResuIts � tecr an,,l
As of E" a search of the prodded name and dale of binh revealed: '
0� No Iowa Criminal HistorY Record found with DCI
❑' Iowa Criminal History Record'altached, DCI P
DCi initiais—yi)
DCT -77 (00511 D)
0euieed,Tkit Oct, 24. 2012 4:08(FM 616, Q90
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(2)
Iowa Department of Transportation
Office of Driver Services (Toll Free) OM -532-1121
PO Box 9204, Des Moines, IA 5030E-9204 515-244-9124
FAX: 515-239-1837
Inquiry Date: 11/7/2012
Name: Bradley, Roger Elliot
Address: 232 Elizabeth St
City/State: Iowa City, IA 52245
Mailing Address: 232 Elizabeth St
Mailing City/State: Iowa City, IA 52245
Name: Bradley, Roger Elliot DL/ID: 435ZZ1025
Certified Abstract of Driving Record
DL/ID #: 435ZZ1025 (IA)
Class: D
Audit #: 2597455
Issue Date: 09/30/2008
Expiration Date: 07/31/2013
Endorsements: 3
Restrictions: NONE
Date of Birth: 7/31/1965
Sex: M
History Information
CLEAR DRIVING RECORD
Customer #:
2308987
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
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:
...........
11/7/2012
IOWA0.
0® Sc`�_----"
Office of Driver Services
aDapi
Iowa Department of Transportation
Name: Bradley, Roger Elliot DL/ID: 435ZZ1025