HomeMy WebLinkAbout13-220 ` Authorization Number
I 1 (Office Use Only)
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) 3f Sn4n CA" ,M C.&JD47 g
(319) 356-5497 FAX
First / Middle Last
1. Name 0-6 x,,,yit 5/vvr-7 1,.,/64.75'
2. Mailing Address 1 i9( 60/11„,,,„
3. Telephone: Home 31/59,/- 3ay( Other:
4. Prior experience in transportation of passengers: tat>i201 r 1=v l/{/(p.. (.,io ' 7W 1,"e
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsevv ,.." 3 I
Type of offense Where
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6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? el u
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
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? Yr f
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)
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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)
clerk/taxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
?SS /24,`";"`/E( . 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 „......-772-..e.-------_/-
/ '.��. Date `l--? (7 -/.3
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscr bed and sworn to before me by [;� ��i� rj S-t�1) QJ/\ L,l<<Cc.ts5 On this c2� day of
II:
V�ENDYS.MINER Notary Publi"in and for the S(:te of Iowa
S,Oaaiwien NwitMr MOM
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).
Ar
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Signa re of P.t'c/Chie 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.
Signa -of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/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
clerk/taxidrivbadgeapp2010.doc 03/2013
Aug. 27. 2013 3: 36PM Div of Criminal Investigation No. 5318 P. 2/2
, — ,,,45. cu. LVID I . myl uity VICIn airy ui ,uwa vi Ly Ivu, Jlol 1. L/7
Ve , 1 • STATE OF IOWA y,° `
'i i :,''ii, . • Criminal.thstory Record Check :(.;p Fc••,e,,:;:
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•04•, on aycp. Request Form -°;e ,/ate
•
- ACI A000unllllmber; ybaa —F
• (Ifapplicable)�
To: Iowa I lidsloh of Criminal I1lvestlagtfon Rrolnf CITY Ore T(1LTA CITY •
Support Opeestions)larenu,1"Floor - CITA CLERICS OFFICE
2.15E,7'4 Street _..4.1.0_1,a
Dos hicifnos,Iowa 60319
(915 725-6066 • IOWA, QIT.Y _IOWA 52240
(615)725-6080 Ito*
Phone; _ 319_356 .5041
• •
lzaka 319—sc6-54,91
l am requesting anlowa Criminal flistory beard Cheek ea: .
Last Name (mandemry) - FirstNB/IIe(mandalory) Middle Name(recommended)
•
. l.vff/LNro 5 S r-:Yt'rY.f 'Awe',
Date Of.8irth(mendefoy) Gon(Ior(mendalnry) Sooial Security Number(raeammollded)
OL-ore - TO ' InMale (]Female S/$-/j-Via,
Woivet•.1'nfonnateonr Without a signed waiver front rhesubiectof the request o complete;Min inalh(slory record may not
be releasable,per Cade oflowa,Chapter 692.2,Y'oN colnhlotobrimhtal history record information)a%allowed by lei;always -
- obtain waiverslgnatarehonl tlte•subieetofthe1•equesri
WaiveP.keteas :lhcrcbygfvepernik,lonforrhoAboverequellingoMofoltocondoelwi/oweodmlardhiatory/atomcha°kwyihlheDivislonofCominol
TnYcengadon(ocp. Arty aiming h(sro,ydata son cmfngnto'ha JsmnlnminadbylhobermoybercicnodweifotvcdbyMw.
WaiverSIgnaeurt; �o✓b
Smo_da r,.,
Iowa Criminal History Record Check Results• . • mel aro onl», _
As of (alai I 1a search of-theprovided name and date ofbillh.revealed:
` i No Iowa CriminalHistorykecordfoundwithDCI
0 Iowa Criminal IlistoryRocofd attached, DC/# •
.
. OCI initials •
1)01.77 (08/25/10) _
Received Time Aug. 20. 2013 1 : 12PM No. 3167 ,
or 1111
Iowa Department of Transportation
is Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/20/2013 DL/ID #: 255DD4944 (IA) Customer#: 4329777
Name: Williams, Clifford Steven Class: D ID Status: None
Address: 161 GOLFVIEW CT Audit#: 6571075 DL Status: VAL
Issue Date: 12/28/2012 CDL Status: None
City/State: NORTH LIBERTY, IA Expiration Date: 01/04/2017 CDL Cert Status: None
523179707
Endorsements: 3 CDL Med Status: None
Mailing Address: 161 GOLFVIEW CT Restrictions: Corrective Lenses Restriction None
Date of Birth: 1/4/1980 Supplement:
Mailing City/State: NORTH LIBERTY, IA Sex: M
523179707
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
02/22/2012 03/20/2012 M14 Fail to Obey Traffic Sign/Signal Johnson IA
03/06/2012 04/11/2012 ,864 No Insurance Card Johnson IA
Sanctions
Type Effective End __ ACD Explanation Occurrence JUR JUR
Suspended 09/04/2012 12/27/2012 D53 Non-Payment of Iowa Fine -IA IA
Name: Williams,Clifford Steven DL/ID: 255DD4944
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:
IN
/4t.-llC1f..4'i, 8/20/2013
FF ti: IOWA \''‘'t
d:
yS. D% . O. T. et
ry�4�Of�RIVEA$R�—J Officowaeof Driver Departme Departmeof nt
Name: Williams, Clifford Steven DL/ID: 255DD4944