HomeMy WebLinkAbout13-143 Authorization Number 1 3 1 f 3
_ i (Office Use Only)
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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 C-Al SDR
(319) 356-5497 FAX
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1. Namega, C
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2. Mailing Address �}6 ,61.4-1vl
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3. Telephone: Home Other: (eT( (3/Q) + ,f—G7 17
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? n
Type of offense Where When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? l7 0
Type of Offense Where When
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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?
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)
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)
clerwtaxidrivbadg 03/2013
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I Acraty
(c r�ti bat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
CI\t� l- ‘`:;/ 7Q . 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 I times with all of the prov. io - of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) I
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Signature of Applican � �-� Date 7 f5
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Atk“4,-- w:1/;,. 12Ce_rA-z. . On this e day of
4 oi3 o y/ SONDRAE FORT
z ,>.r. Commission Number 159791 S
• a • M Comm cion E a Notary Public in and for the State of Iowa
3/7 ,?vt
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).
7/g///3
Signature of olicihief 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.
/
Signatu`e_of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width)and 5 1/2"
(height) and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
clerWtaxidrivbadgeapp2010.doc 03/2013
Jul. 3. 2013 3: 24PM Div of Criminal Investigation No. 9197 P. 1/10
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rim Received Time Jun. 28. 2.013 10: 30AMr�'rt,1a"8637Pg----- •
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Iowa Department of Transportation
404 Office of Oliver Services (Toll Free)800-632-1121
PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
Now FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 6/28/2013 DL/ID#: 212CC3179 (IA) Customer#: 2175850
Name: Willingham, Matthew Class: C ID Status: EXP
Cleveland
Address: 2826 MUSCATINE AVE Audit#: 5321904 DL Status: VAL
Issue Date: 06/23/2011 CDL Status: None
City/State: IOWA CITY,IA Expiration 04/19/2014 CDL Cert None
522402801 Date: Status:
Endorsements: NONE CDL Med None
Status:
Mailing Address: 2826 MUSCATINE AVE Restrictions: NONE Restriction None
Date of Birth: 4/19/1978 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522402801
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
01/28/2009 103/12/2009 1651 INo Driver's License 52 IA
Name: Willingham, Matthew Cleveland DL/ID: 212CC3179
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:
ocQ*NCIf* 6/28/2013
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* = c& ''v-is Iowa D partme tOffice of Driver oofiTransportation
Name: Willingham, Matthew Cleveland DL/ID: 212CC3179