HomeMy WebLinkAbout12-272CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1926
(3 19) 356-5040
(3 19) 356-5497 FAX
1. Name
2. Mailing Address
3. Telephone: Home
4. Prior experience in transportation of passengers:
61
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Other:
,� - a 7a -
(Office Use Only)
Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
T eofoffense 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? �[�j )
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Tvpe of offense Where
0'e5
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? -
Tvpe of offense Where When
In e -e1-7
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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)
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)
derMamdriwedg 09/2012
I herebcertify that I have issued—to me by the Iowa Department of Transportation a valid Chauffeur's license number
R J � % !�j !�e S S . I understand that if I falsely answer any questions in this application, that this
alYplication 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�� zl
******#**#**#****####*#**####4*#*4***#*********************Yk**Y#**f*Y****Y#*#**Y***Y*********M#****fk*****##***#**YY**#****#**#*#*###t########
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Mani,, 1(1/ls. On this ,/ day of
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).
Sig lure of oy •e lief or designee
it -a J -/,a
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.
SignatbTe of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Date
*#****################4###**4****R*******#**Y#**********#*#********####**#********#**Y#**RYYf***Y#*#**#***###*#Y*#*###*#***##**########*##******
Office Use Only
Approved application
DCI report
State certified driving record
Website update
deM1 idnv adgeapp2010.tl 09/2012
ARTS Page 1 of 1
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Iowa Department of Transportation
Office of Driver Services (Toll Free) 890-532-1121
PO Box 9204, Des Moines, IA 58366-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
11/20/2012
DL/ID #:
813ZZ4955 (IA)
Customer #:
2937222
Name:
Hillsman, Marvin Russell
Class:
D
ID Status:
None
Address:
291 27th Ave Sw
Audit #:
1784891
DL Status:
VAL
Issue Date:
01/10/2008
CDL Status:
None
City/State:
Cedar Rapids, IA 52404
Expiration
03/30/2013
CDL Cert
None
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
291 27th Ave Sw
Restrictions:
NONE
Restriction
None
Date of Birth:
3/30/1942
Supplement:
Mailing City/State: Cedar Rapids, IA 52404
Sex:
M
History Information
Convictions
Citation Date Conviction Date ACD Explanations County IUR
05/29/2009 06/03/2009 Speed (10 mph & under in 35-55 mph zone) 52 IA
Name: Hillsman, Marvin Russell DL/ID: 813ZZ4955
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:
Name: Hillsman, Marvin Russell DL/ID: 813ZZ4955
11/20/2012
11/20/20120. '
IOWA `
W
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Office of Driver Services
ORIVER,_=-
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Iowa Department of Transportation
Name: Hillsman, Marvin Russell DL/ID: 813ZZ4955
11/20/2012
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STATE OF IOWA
Criln1nal History Record Che.ek
i . "MI
Requesi Formti
Ta; lown Dividon of Crltctnal Investigation
Support Operations Bureau, V Floor
21S B. 7" Strut
Des hfolnes, Iowa 50519
(515)725-6066
(515) 725,6080 FAX
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DCI Account Number: q q to
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fitt orutalfort: R4thout a signedwaliprfrom thesublttct of the raquesl, a complete crlinlnnt history record may net
releasablq pct Code of Iowa, Chapter 692.2. For eamplete criminal history reeord Information, as alloyed by la+\•, at+veys
Ylv(tdverRekr.�17Se;Ihlrcayelvdpurninloafor Elio ebuYerequesanloblclaltocan dim augcriminnlLlslatyrcedtdchetL:mill uerfivixldn)I'Orlminel
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xYatverSigrtature:_ -_ry __
TQ�CxtminaY ]l-istorV Record Check ResulEs PC+Vic Vd,,.)
.1 of //!/ �% //? a search of tha p> ovided namc and date of birth revealed;
No Iowa Criminal Flistoly Record found with DCI
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❑ Cowa C riwinal History Record attached, DGI
Nlti DCT itliYials ��—'
7aC1-77 (a812511u)
Received Time Nov. 9. 2012 1;59PN No.3610
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