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HomeMy WebLinkAbout13-255 Authorization Number r1z. 1 (Office Use Only) Z-TZZIZI mai mos i 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) 356-5497 FAX First Middle Last , 1. Name 0 t.kc c\C (�R 11^a +<�`i©U. 2. Mailing Address (,t,kkjSPr 1ii AVQ OLk.. C-j-tiI A Gi2LAC 3. Telephone: Home Other: 3(9 6' )_1 4- 4. Prior experience in transportation of passengers: l 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /MN 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? V Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When q 5v(cct :20k,A f ti ��' l j W-t C-41) to /07 (c 1 Sp ec -p-cw.f1 o`1 /,)" 3 / 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ivv 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) Mi\k-kAI\AAV, —t R,ac, 1:L 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) derknaxidrivbadg 03/2013 I hereby certify that I have(-,0 i�sued to me by the Iowa Department of Transportation a valid Chauffeur's license number - 11 p77 qU 1. I understand that if I falsely answer any questions in this application, that this application may be denied.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 ((/-y/i$ ******k**********************************:tic***************************************************************************************************** STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by :i-yr,L , r,,,r 1ti._ i\;0,1 ) p . On this y day of f\) .kvUll ti �Q13 ,� 1 (i ce s /t1 -� .� WENDY S.MAYER Notary Public in ajidfor the State of o a i C,.,n.,.,;asio„Njmbe,7P94404• My Commission Expires iow -2--) 1.L 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). i —! ./- z-/--/Signa re of Po!'er i- 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. � ma k . „„, It/L /j j ign re of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/2” (width) and 5 1/2" (height)and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update derk laxddrivbadgeapp2010.doc 03/2013 Oct. 11. 2013 11 : 50AM Div of Criminal Investigation No, 1044 P. 1/6 vu 1. I. [VU 7 .71nm oily t.ieta t, i ly ui luMa vi lY N u, )707 1. 4/ 4 rr STATE OF IOWA • '''A. .:1019n‘•v, Criminal History Record Check • �' 11= �A Al,' . Request Form 1; 11,14 • DCI Account Number: 4+(3 0-3,.- 0 f applicnble)-3,.— (ifapplicnble) To: Xowa Division of Criminal Investigation From: CITY OF IOWA CITY • Support Operations Bureau,1"Floor CITY CLERIV'S OFFICE 215 B.7th Street 410 E WASHINGTON STREET • Dos Moines,Iona 50319 (516)775-6066 Inue rT v TOWArS-2240 (615)725-6080 Fat 7 k \k Phone: 319-3565041 Fax: 319-356-5497 I am requesting an Iowa Criminal History Record Check on: • Last Name (mandatory) First Name(mandatory) Middle Name(recommended) Di A]LO 1300.8 A( AR frt 01 k.). Date of DIrthjmandatory) Gender(mandatory) Social Security Number (recommended) it oZ ( T 1 tg IIQMaIe ❑Female 141 ? 3 3 6 0 6 WaltverInforntation: Without a signed waiver from thesubject of the request,a complete criminal history record may not he releasable,per Code of Iowa,Chapter 692,2.Forcomplete criminal history record information,as allowed by law,always Obtain a waiver signature from the subject of the request, Waiver_Release;I hereby glva permission tot the about,matins(lug. ofliciel to conduct an Iona criminal hie tory record cheekwith the Division of Criminal Investigation(DCI), My criminal history data concerning mo diet ly Stained by theDCl maybe ecleased as efowcd bylaw_ Waives'Signature; 0X.A r/ \ ' ^^ r-- pp c. Iowa Criminal History Record Check Results (DCIuse only) As of k,0 \A0 1 13 , a search of the provided name and date of birth revealed: . • • p No Iowa Criminal History Record found with DCI • 0 • Iowa Criminal History Record attached,DCI 4 DCI initials Received Tim1?Oct."1. 99013 9:51AM No. 0347 r . . Iowa Department of Transportation Office of Driver Services ([dl Free)B00-512-1121PO Box 9204,Des Manes, fl IA 503D6 92D4 515-244-9124 FAX:515-239-1E137 Certified Abstract of Driving Record Inquiry Date: 10/22/2013 DL/ID#: 960225901(IA) Customer it: 362217 Name: Diallo,Boubacar Matllou Class: D ID Status: None Address: 2547 WHISPERING PRAIRIE Audit#: 7347317 DL Status: VAL AVENUE Issue Date: 09/17/2013 CDL Status: None City/State: IOWA CITY,IA 52240 Expiration Date: 07/08/2017 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: 2547 WHISPERING PRAIRIE Restrictions: NONE Restriction None AVENUE Date of Birth: 7/8/1978 Supplement: Mailing City/State: IOWA CITY,IA 52240 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County IUR __. ,......._._ _ .. .9.. ..._-..__.._..._.� --11178-97-TS-Pt __... . s....r.__ 04/22/2009 05/1/19/2009 592 ISpeetl ']ohnsan 7A 10/07/2009 01/27/2010 ____ _1592 _ ISpeeO_ __ lohnsan '3A 09/23/2012 10/19/2012 592 SpeedJohnson IA Name:Diallo,Boubacar Medico DL/ID:960225901 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 1DDrepartment to be set upon this document,at Ankeny,Iowa this date: _Olio Ir,, O�� •.......-.j 11 10/22/2013 (çC) eam8 t11j11ces 0��m`rog Iowa aD Deof partment tiver eoflT Transportation NIYEA,e. Name:Dlallo,Boubacar Matllou DL/ID:950225901