HomeMy WebLinkAbout13-167 V Authorization Number 3 l6
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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 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First fiddle Last J
1. Name ["� G S ��.J cY r� `.0 -- --
2. Mailing Address �D 1 1 1 . Co E — 4-3`74/ I *iQ c1-i-y, 1�
1 � - -q ` 2qo
3. Telephone: Home (319)-338 -2 012. Other: 512 /0JS S2L I
4. Prior perience in ansportation of passengers: Q,r%Ve„�-NX I r 1/0 C. ! ! �(
or- cr YI!ow Cyer-6
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 1 V Q
Type of offe ssee Where When
6. Have you benonvicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? f� Q
Type of Offens Where When
N/A
7. Have you been convicted of any traffic offenses in the last five years? Ye,5
Type of offense Where When
SPecac4 i n3 Linn Cour- 1yV-1.0
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N 0
Type of oe Where When
N
9. Have youfiver applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
0
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)
03/2013
I
I hereby ce_Jify that I haves issued to me by the Iowa Department of Transportation a valid Chauffeur's license ftnber
7(0-7 7 7 1 3 . 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) /
/ Q 1
Signature of Applicant / - ' 3
a 1
PP �� •'��!>/" " Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by r;h o mai se4f- . On this / day of
u!�• SONDRAE FORT
Commission Number 159791 Sz14
My Cog mi7 sn,Fgr .s Notary Public in and for the State of Iowa
************************************************************************************************************************************************
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).
Signa r of Po c'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.
Sign e of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/2" (width)and 5 '/2"
(height) and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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derWtaxidrivbadgeapp2010.doe 03/2013
ARTS Page 1 of 2
Iowa Department of Transportation
Office of Driver Services (Toll Free)899332-1127
PO Box 9204,Des Manes,IA 50305-9204 515-244-9124
4411. FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/1/2013 DL/ID #: 769YY6103 (IA) Customer#: 915880
Name: Heath, Thomas Edward Class: D ID Status: None
Address: 2801 HIGHWAY 6 E LOT Audit it: 6044993 DL Status: VAL
394 Issue Date: 06/13/2012 CDL Status: None
City/State: IOWA CITY, IA Expiration 05/19/2017 CDL Cert None
522402658 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 2801 HIGHWAY 6 E LOT Restrictions: NONE Restriction None
394 Date of Birth: 5/19/1959 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522402658
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
10/07/2006 (10/31/2006 '1361 Violation of Accident Requirements .Johnson SIA
07/07/2013 07/18/2013 ,592 :Speed :Linn IA
Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
09/19/2011 648797 ;IA
Name: Heath,Thomas Edward DL/ID: 769YY6103
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:
pEN�C!E N
F.4... veil, 8/1/2013
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yl' irvices
n bR s.F. Iowa Department eof Driver erfTransportation
http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 8/1/2013
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