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HomeMy WebLinkAbout13-276 Authorization Number / 3- a. [Q I - 1 (Office Use Only) 4r ,rlll ftt MOM ZIT APPLICATION FOR TAXI DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday-Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX ,7) First addle Last 1. Name f 1�c.‘7\ 1l �- GAF ��©i /1)17�1�OC 2. Mailing Address /5(9 llACI GJ 6)(. k. iF 3. Telephone: Home 5/7- 17).5- -`�R-/ -3 Other: 4. Prior experience in transportation of passengers: 6 5 -Fr f X 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?- 27-.70 0 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? /LQ Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When Uttevt5 UA-`; cm. w/A-`r (5(itp4t..rn `/ z 1/ 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /1_,;,-) 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) 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) clerkitaxidrivbadg 03/2013 P I hereby„certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 0 3 2 3 6 . 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 e pro isions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Appli•ant � Date I P-1/6//5 V **** *************************************,********************* ***********************************************..****************** STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by L Y P U n c . On this / o --Ll., day of WENDY S.MAYER Notary Public in a for the State of low 1442. e+ Cerniesiea-N ahar 729428 My Commission Expires "7—i>.—ll-P ************************************************************************************************************************************************ 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). 2f/p05 ignature of Police Chief 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. Signat of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5 1/3" (height) and prominently displayed to all passengers. ************************************************************************************************************************************************ Office Use Only Approved application DCI report State certified driving record Website update • clerlvtaxidrivbadgeapp2010 doc 03/2013 trAIowa Department of Transportation Office of Driver Services (Toll Free)800-532-1121 PO Box 9204,Des Manes,IA 50306-9204 515-244-9124 FAX:515-2391837 Certified Abstract of Driving Record Inquiry Date: 12/4/2013 DL/ID#: 803ZZ2363 (IA) Customer#: 3636560 Name: Vornbrock, Rick Page Class: D ID Status: None Address: 150 PADDOCK CIR Audit#: 6633584 DL Status: VAL Issue Date: 01/22/2013 CDL Status: None City/State: IOWA CITY, IA Expiration 01/09/2018 CDL Cert None 522407201 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 150 PADDOCK CIR Restrictions: Corrective Lenses Restriction None Date of Birth: 1/9/1951 Supplement: Mailing City/State: IOWA CITY, IA Sex: M 522407201 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 08/18/2013 08/21/2013 N63 Driving Wrong Way on One Way Street Johnson ':IA 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: W qN\\ i$t.. ..... 12/4/2013 Si ' O. T.OWA .CPIa% 'f r: :o's t ,f•j aI;D. O. T.,'Ws ,, adepria ,''CF.,alb Iowa Office of Driver Services Departme tof Transportation Name: Vornbrock, Rick Page DL/ID: 803ZZ2363 ' ,`IDe . 10. 201 1Et::56AM Dii+vyo,f eClrrim-inallyIuvesuwa tion NNo.13555 DP. L1/3 rnpi,;,� STATE OF IOWA ��D�, V�t,ar i. i �'� �° + Criminal History Record Check 'x `- lo tl\ffccli:ik a,J.A'./ Request Form .i.w�".t�+('� DCI Account Number: l/ODZ -F' (if applicable) To: Iowa Division of Criminal Investigation Saoim CITY of Tom CITY Support Operations Bureau,1"FIoor CITY CLERK'S OFFICE 215E.7'f'Street 410 E WASHINGTON STREET Des Moines,Iowa 50319 (51012S-6066 IOWA CITY IOWA 52246- (515)729.60/10 Bax Phone; 319-3565041 • Fax: 319-356-5497 I am requesting an Iowa Criminal History Record Check on: " Last Name(mandatory) Z+irstNalne(mendnlmy) Middle Name(rccommended) • VigluaROCK. 61 bk FA GE Date of Birth(madman) ' Cender(mandatory) Social Security Number(rccommcndcd) / ! q l ri INMale °Female 5 Li- G 8- ?,5- z 1 • Waiver Information:Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 6922.For complete criminal history record Information,as allowed by raw,always obtain a waiver signature from the subject of the request. Waiver Release:lhcrcby give permission for ha abovo radios llnpoffidal to co•duct an Y. 'a criminal hBlmyrccord oheok wllh the Division of Criminal Investigation(DCI). Anycriminal history dataca,- inn-me ik• is etnlal d by lhq i CI...ybereleased as allowed by law. Wa(verSignatur., .( w a : --=!4 IL . Iowa Criminal ` istory Record Check Results (DOruaoonly) As of a_ e gr. /3 ,a search of the provided name and date of birth revealed: • No Iowa Criminal History Record found with DCI ✓❑ Iowa Criminal History Record attached,DCI# DCIinitiuls -0 • Received Time7•Nov, 26. 4013 4:02PM No. 3323