HomeMy WebLinkAbout13-132 Authorization Number `J
i (Office Use Only)
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
4 1 0 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.)
Iowa C itIowa52240-1826
(CCU 9)_3,56_594D)6i0n 4i1
(319) 356-5497 FAX
61/50/t
►► First G Middle as
1. Name C1/=0/t ()G' / l /. ( / e/;." ( (' r010
2. Mailing Address `, 0, igv '?6 Lk)ALL/1A� T A 5'2_3
3. Telephone: Home Other(CEL )
L1 3/ 933 /P2 {
4. Prior experience in transportation of passengers: /- ' A A)It s TA 't I / OCA NS )D
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Al
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? i(/
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 2/ (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? ,/ !J
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)
AJ U
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)
derWtaxidrivbadg 03/2013
I hereby certify that I have issed to me by the Iowa Department of Transportation a valid Chauffeur's license number ,
7o �J r) 6d, / . 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 ,/-1./-619-C7., Z. Date v / ? /3
v6/-zel- / 4/( .
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STATE OF IOWA )
COUNTY OF JOHNSON ) r
8 S bscribed and sworn to before me by �� e v Y' i C—�T0Y' , On this �� day of
,.. ,i(,i i'_F i -- I'17 cj /
�PsiAt s KELLIE K.TUTTLE / C (,'£. / 7L{ /(
`_ f co�missfo Number221819 XpirpC 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.ure of Pc, ic= Chie or designee Date
t /
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.
ui `e. -/ 7
Signature of City 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
clerk/taxidrivbadgeapp2010.doc 03/2013
Page 1 of 1
Iowa Department of Transportation
awwi Office of Driver Services (Toll Free)SC0-532-1121
PO Box.92114,Des Moines,IA 50396-9204 515-244-9124
a` FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 6/7/2013 DL/ID #: 700AJ0627 (IA) Customer#: 6101512
Name: Bickford,George Class: D ID Status: None
Frederick IV
Address: 401 9TH AVE Audit#: 7011629 DL Status: VAL
Issue Date: 06/06/2013 CDL Status: None
City/State: WELLMAN, IA Expiration 01/15/2018 CDL Cert None
523569338 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: PO BOX 296 Restrictions: NONE Restriction None
Date of Birth: 1/15/1967 Supplement:
Mailing City/State: WELLMAN, IA Sex: M
523560296
History Information
CLEAR DRIVING RECORD
Name: Bickford,George Frederick IV DL/ID: 700A30627
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:
111th 4.114,
. 1 6/7/2013
IOWA *°
°give
//l,Il r�f gRIdENRr IoOffwa Department of Driver
ov�TServices
ansportatioo
Name: Bickford, George Frederick IV DL/ID: 700AJ0627
6/7/2013
Jun. 14. 2013 1 : 22PM • (0iv of Criminal Investi,gationl 1\12.1‘,6,1,9_,9 PP. el
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Received Time Jun. 11. • 2013 11 : 18AM No. 6496 - .
Page 1 of 1
Iowa City DL Station
Eastdale Mall 1700 S First Avenue Iowa City, IA 52240
Statement Receipt: 30315393
Customer Information Office Information
Name: Bickford, George Frederick IV Date: 6/7/2013 11:10:52 AM
Address: 401 9TH AVE WELLMAN,IA 523569338 Location: Iowa City DL Station
Phone:
Fax:
Email:
Attached Customers
Name
Bickford, George Frederick IV
Transaction
Type Description Amount
MISC Finance Transaction -Bickford, George Frederick IV $5.50
Product Amount
Sale of Records-Certified $5.50
Total Due: $5.50
Payments
Payment Method Payor Payor# Number Amount Tendered
Cash Bickford,George Frederick 6101512 NA $5.50
IV
Total Tendered: $5.50
Cash Back: $0.00
6/7/2013
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i:•,4•business. It is the business of thel 'Stork Statetpdpartment of Motor Vehic es,t� r ate�a d t,aaintain the records of drivers in the $ •
? ri state of New York. Entries in this document are matt the time the recorded tre�ac ke f nts took place or within a reasonable
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IOWA ISA
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DRIVER LICENSE ` e +, •
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,BICKFORD ' - -
GEORGE FREDERICK IVt`__
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i-" -'94019TH'AVE -``f
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WELLMAN,IA, 2356 1, -. '.
DL No.700AJ0627 r i ,;
'iss 0610612013. EX? 071,420131 _• .
End 3. Sex
Cfa, Restnctians 4,• Eyes BLit .
�q�� q ` -I NONE
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' 00 670116297BG1206M1601180