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Home My WebLink About13-241 • • Authorization Number J 3 - oZ l (Office Use Only) -- .®Rl Air CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER (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 First Middle Last 1. Name KA{ L. LA2SEN 2. Mailing Address -1.30 T-,ri:t c. ZA Sa 3 S` 3. Telephone: Home Cl1v')a)3 -`71t7 0 (c'e 6 Other: 4. Prior experience in transportation of passengers: 5. Have you ear been convicted of any misdemeanors and/or felonies in this State or elsewhere? ,yam 'sK.o µ '= Type of offense Where When - 1_-- `�. '1St 63 A 14 �,3 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? NC.. Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? A-1(> Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A-) O 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) �.} C-) 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) clerkllaxidrivbadg 03/2013 • I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 3(G Q 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 and documents relating to this application, and I further agree that, if a license is granted, to comply at all times - 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 ' •.7 Date ************************************************************************************************************************************************ STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by Ic - . 1 1_�C�,e . On this -Ct, day of C? c k-b-1631.c �-C�l c • % .' PS Ai , • otary Public i'and for the St.r-of Iowa mrressIon Number 729428 My Commission Expires ow 1- - 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). e c, F, .P0/3 Sign ture of Polio ief 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. 73(77 / Signat re of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2"(width)and 51/2" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update • derkdaxidrivbadgeapp2010.doc 03/2013 Oct. 5. 2013 5: 57PM CDiv of Criminal Investigation NNo. 8250 P.P. 1 • STATE OF IOWA Criminal History Record Check / �= • lawn ) '. • ,. Request Form ` DC'Account Number; t(rx 4-'{� (If applicable) To: Iowa Division of Criminal Investigation iirom: CITY OF IOWA CITY Support Operations bureau,lrtFloor CITY CLEWS OFFICE 215 E.7"Street 4L0 E WASHINGTON STREET Des Moines,Iowa 50319 (515)725-6066 • (515)725.6080 rax Phone: 319-3565041 Fax' 319-356-5497 I am requesiing an Iowa Criminal Historynecord Check on: • Last Name (mandatory) First Name(mandaiury) Middle Name(recommended) p�sE LOLQ 1 Date of Birth(mandatory) Gender(mandatory) Social (Security� Number(recommended) / A h.1 6 S Rl i1 f Male ❑Female `i �j �+ —g Waiver 1)t/ormallofa Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 6942.For complete criminal history record information,as allowed by law,always obtain a waiver signature from the Babied of the request. • Waiver Release7Ihereby give permissionfor thoabovetequeslid.l clettoconduetanIowa orrndnelhlstoryrecord check with llwDivis7onofCriminal Investlgatlon(DC!). Any criminal history dataconeemin: isnedbythIeDCIlmaybereleasedasallowedbylaw. • ria rtr Waiver Signature: / - / ( (J 4D..4_491-- Iowa Q Iowa Criminal History Record Check Results (DCC!use only) As of a search of the provided name and date of birth revealed; • : • Cd No Iowa Criminal History Record found with DCI 0 Iowa Criminal History Record attached,DCI# DClinitials • 6 Received Time7'0c1. 1. 1(2013 2:33PM No. 9670 Iowa Department of Transportation f� OtceofDriverServices (Toll Free)90D-5324121 PO Box 9204,Das Minos,IA 50305.0209 515-244-9124 FAX 515-2394837 Certified Abstract of Driving Record Inquiry Date: 9/23/2013 DL/ID#: 343AE8601 (IA) Customer#: 5515146 Name: Larsen, Karl Louis Class: B ID Status: None Address: 677 W 8TH AVE Audit#: 5190057 DL Status: VAL Issue Date: 04/29/2011 CDL Status: VAL City/State: MARION, IA Expiration Date: 01/18/2014 CDL Cert Status: None 523022730 Endorsements: P CDL Med Status: None Mailing Address: PO BOX 93 Restrictions: Motorcycle Restriction CDL Instruction Instruction Permit, Supplement: Permit Expires Commercial 9/24/2011 Instruction Permit, Corrective Lenses Date of Birth: 1/18/1970 Mailing WEST BRANCH, IA Sex: M City/State: 523580093 History Information CLEAR DRIVING RECORD Name: Larsen, Karl Louis DL/ID:343AE8601 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: yaAI E Skil 9/23/2013 14. . s� i IOWA•*l WJJ) ct*t!,m Office of Driver Services Iowa Department of Transporation Name: Larsen, Karl Louis DL/ID: 343AE8601