HomeMy WebLinkAbout13-242 Authorization Number 1 $—#2`4,c2
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East Washington Street between 8 a.m.to 3 p.m., Monday-Friday.)
Iowa City,_Iowa 52240-11826
((319) 356-5Q411A-
(319) 356-5497 FAX
First Middle Last
1. Name LZ c kg, 1"/:
L✓:(( h<�y
2. Mailing Address (( L S 51 . C ('�-- �3 A-tt-Gy
3. Telephone: Home 31 K 3 3 0 6 '1 2. 0 Other:
4. Prior experience in transportation of passengers: I ,ti4,r s J 5, (q 4 c)
.� 9 , , T-r.. Tax;
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or �s �=enrkp
Type of offense Where Mien
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? n O
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? --t$
Type of offense Where When
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense Where When co‘,
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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)
L c t ti/.�C�-t� (7)
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)
derk/taxidrivbadg 03/2013
I hereby ceigy yayh v s d to me by the Iowa Department of Transportation a valid Chauffeur's licence number
1 6 ( 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 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 v ,ii//� Date (((
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Lee !tk . LA.), ) 1 b e. ; . On this c'±-1& day of
WENOYNunS. YE � t ary Pub i and for the Stat of Iowa
-1c-i ort&Tnissiort
Expires
************************************************************************************************************************************************
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 ture of •/.liF 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.
772 - • -kZ1i- ) �/G 1 r 3
Signat re of �CriClerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5 1/a"
(height)and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
derk/taxidrivbadgeapp2010.doc 03/2013
Sep;. 1.7.. 20133 4: 21PM1 Div of Criminal Investigation No. 8023 P. 5/11
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ET YowfchsnutlitgPoxpRecord attached,I)Cn# ,
Received Time Sep. 12. 2013 3:24PM No. 72.92 j, ' I
Page 1 of 2
in Iowa Department of Transportation
Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Manes,IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 10/4/2013 DL/ID #: 760YY4065 (IA) Customer#: 1827411
Name: Wlllberg, Lee Marinus Class: D ID Status: VAL
Address: 935 E COLLEGE ST Audit#: 4646795 DL Status: VAL
Issue Date: 09/02/2010 CDL Status: None
City/State: IOWA CITY, IA Expiration 07/17/2014 CDL Cert None
522405536 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 935 E COLLEGE ST Restrictions: NONE Restriction None
Date of Birth: 7/17/1980 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522405536
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
05/31/2010 08/09/2010 S15 Speed IL
10/29/2010 11/02/2010 !S92 Speed Linn IA
04/07/2011 04/07/2011 1592 'Speed Johnson IA
07/14/2012_ 07/25/2012 1592 'Speed .Johnson .IA
08/04/2012 09/05/2012 :M14 Fail to Obey Traffic Sign/Signal Johnson IA
Name: Wlllberg, Lee Marinus DL/ID: 760YY4065
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:
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< eof Driver ntlElt Iowa Department Transportation
Name: Wlllberg, Lee Marinus DL/ID: 760YY4065
10/4/2013