HomeMy WebLinkAbout13-147 Authorization Number 1 3 - ) L{
" (Office Use Only)
firanlairil ALM
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
J CAS0i-irst / dle ( �L 6
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1. Name � /
2. Mailing Address l l Ht AvsC ( f�-
3. Telephone: Home �� 1 3 " L[ 15 Other: n�
4. Prior experience in transportation of passengers: 0 LUQ Cc,v ,��,l o CAI U " av'c 0 5
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 1A'0
Type of offense Where When
6. Have yobpfen convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? J�
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? (.11f
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? IVO
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)
I
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 heeby certify that I aveissued to me by the Iowa Department of Transportation a valid Chauffeur's license number
//`` (a `) . 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 i e provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
J� r
Signature of Applica / Date
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn ,to before me by }� `—'C r L . On this 1 � day of
f;' ,r KELLIE K.TUTTLE ��� �� l �
,Commission Nu ber 221819 Notary Public in and for the State of Iowa
o
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).
gnature of Police 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.
J 7 1
��Z-C/E'JL� L.--Y
Signa re of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/z" (width)and 51/2"
(height) and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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clerWlaxidrivbadgeapp2010.doc 03/2013
frif% Iowa Department of Transportation
Office of Drive(SoMces (Toll Free)coo-532.1121
PO Box 9204,Ccs Manes,IA 5030.5-0204515-244.912472o4 FAX:515.239.1837
Certified Abstract of Driving Record
Inquiry Date: 7/6/2013 DL/ID#: 554XX0675(IA) Customer#: 1297025
Name: Andrew,Jason Class:
D ID Status: None
Andrew
Address: 1110 HIGHLAND Audit#: 4442439
DL Status: VAL
AVE
Issue Date: 06/17/2010 CDL Status: None
City/State: IOW
A lCITY, IA Expiration Date: 04/26/2015 CDL Cert Status: None
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Endorsements: 3 CDL Med Status: None
Mailing Address: 1110 HIGHLAND Restrictions: Corrective Lenses RestrictionAVE None
Supplement:
Date of Birth: 4/26/1960
Mailing IOWA CITY,IA Sex: M
City/State: 522402155
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number JUR
03/17/2009
499408 IA
06/11/2009 512880 IA
Name:Grubbe,Jason Andrew DL/ID: 554XX0675
Pursuant to Iowa Code 4321.10, 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:
y..N ImAA
Wit it AN, 7/6/2013
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LVD. 0. 1. ,
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�1�4 .h �+81 Office of Driver Services
Iowa Department of Transporation
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9 State of Iowa \SRP+'Or_101 4.,
1 � - ��f Division of Criminal Investigation ` s y
,► i q",., 215E 7n'St -c/" ° 7
c ,/ IOWA' : �` Des Moines IA 50319 r of P 0'e a,
L Ph.515-725-6066 Fax 515-725-6080
olf `�y�e Iowa Criminal History Record Check Rr"t"pl
1
Walk-In Request
Your name SG.SO 1.. &rut 11 10 A
Address 1 l l 0 k-- i 51-+ la. t--. t v V
City/State/Zip7Z 0 Wo_ C ;4 ii LA 5 -2.2_,f a Fill in all shaded areas.
Phone# 3 ( f -q ; c — I' ic-
Requesting an Iowa criminal history record check on:
Last Name Apellido(mandatory) First Name Primer Nombre(mandatory) Middle Name Segundo Nombre(recommended)
.‘cLA\o‘neJ 0.Cot � �.d�few
Date of Birth Fecha Nacimiento(mandatory) Gender Genera(mandatory) Social Security
Number(recommended)
LJ 2- 6 / I G G 0S Ce ❑Female I b J —Ip (9- 6 I4
Waiver Signature Firma the equest is on yourself,please sign. if the request is on someone else,write N/A.)
9 . .
Results DCI USE ONLY
As of 4, `/C/3, a name and date of birth check revealed:
No record found
/////❑��``Record at ached,DCI#
DCI initials nil -.
Receipt
Number of requests ( x $15.00 per last name=Total amount$ I S• 06
Method of payment: ❑cash ❑money order '$Check# 3 7-10 ❑MasterCard or Visa
Cardholder's na/t(e Last 4 digits of MC or Visa
DCI initials
Credit Card Number# Exp. Date