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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
19) 356-SO40 F/, 14-7
(3 19) 356-5497 FAX
n I , First
1. Name
Authorization Number /a' a S l
(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 1570 C- K LIP,,
3. Telephone: Home 19 U 2 3 Other:
4. Prior experience in transportation of passengers: �5 `1e.40 S 7 A'.: d Kiy
Last
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?_
Type of offense Where When
6. Have you Pep convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
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 drivers license or chauffeurs license been suspended or revoked in the last five years? /VQ
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) /Jo
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)
cle .iddwbadg 09/2012
I hereby gertify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
V i 2 z �� (o �i 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 nd documents relating to this application, and I further agree that, if a license
is granted, to comply at all times with all of the rovisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) , z—) i Z
Signature of
Date (°Z
STATE OF IOWA )
COUNTY OF JOHNSON )
S�hscribed and swom to before me by �t`t �\Cy er h� v � A( On this day of
?
kVA 0 13 II`1
clic in and for the tate o wa
fiRRR*RRA**RR*R*#**R*RR1R*f#R}#Rf}#1R#*1Rf}1f#t*Rti#RR}#*4R}*R*******RR#*A#*R#RR**#i*#4###if##Rfif1111f}1R111f1tR411411ti+#f3H4##f4f4333#3#3Rf}t
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).
_4V4�41
Signature of Pol' € hief or designee
// /
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.
-7)7
Signatdwof 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
4-//-/�
Date
deAN idriWadyeepp2010.d 09/2012
Iowa Department of Transportation
CX Office of Driver Services (Toll Free) 300-532-1121
PO Bax 9204, Des Maines, IA 5030fi-9204 515-244-91244
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
12/7/2012
IOWA�;r
DL/ID #:
803ZZ2363 (IA)
Customer #:
3636560
Name:
Vornbrock, Rick
Page
Class:
D
ID Status:
None
Address:
150 Paddock
Cr
Audit #:
1699509
DL Status:
VAL
Issue Date:
12/07/2007
CDL Status:
None
City/State:
Iowa City, IA
52240
Expiration
01/09/2013
CDL Cert
None
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
150 Paddock
Circle
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
1/9/1951
Supplement:
Mailing City/State:
Iowa City, IA
52240
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Vornbrock, Rick Page DL/ID: 803ZZ2363
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:
•;`i'4
12/7/2012
IOWA�;r
^ ••S_
Office of Driver Services
r.DRIO �'
Iowa Department of Transportation
Name: Vornbrock, Rick Page DL/ID: 803ZZ2363
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