HomeMy WebLinkAbout13-129 Authorization Number
I 1 (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 � , z
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12. C
_356-5040_ wt-` 'e�
(319) 356-5497 FAX
Fi t Middle f t Last
,Z1. Name �� e 1" �f �(,[ .e.3
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2. Mailing Address 5!0 - /3 ( �i,y rL A 141,4 L � eprajVr /if(- 14 17 G1(
3. Telephone: Home 1 Q Log- I L4 Other: 316? q 3 0 7 7
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Al t_)
Type of offense Where When
6. Have you een convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? A) 0
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
110
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)
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)
derk/taxidrivbadg 03/2013
I hetebv certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
'- / V , 0 5 7 57 ) . 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) // // /
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Signature of Applica h, / ,p4.../-� Date -7(L
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Le 4c r .-�e ss . On this 7 day of
�kn/ c:2-a./ � .� !,
o �s SONDRAE FORT SeT�v�4�
Commission Number 159791
My Commission Expires Notary Public in and for the State of Iowa
3 z -7/ '2 a`.i
************************************************************************************************************************************************
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).
1 .ti/"--- //-//-7 3
Signature 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.
Signa ftrre 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'/2"
(height)and prominently displayed to all passengers.
********************************************************************************************************* ,.,,,,..***************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
uar<,;ax.d ,bddyeac:p2010d = 03/2013
Jun. 5. 2013 12:48PM Div of Criminal Investigation 1,Nu.o.587r5 •1P .• e8/8
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Received Time Jun. 3. 2013 I :36F No. �531O 1 •
Page 1 of 1
Department of Transportation
I•. i. .owaS
Office ofDriver SerVices (Ted Free)600532-1121
.. PO Box 9204.Des Maines,IA 50306-9204 515-244-9124
FAX:515-239-1637
Certified Abstract of Driving Record
Inquiry Date: 6/6/2013 DL/ID#: 279AD3750 (IA) Customer#: 5360870
Name: Burgess, Lester Vern JR Class: C ID Status: None
Address: 1605 North Jones Blvd Audit#: 2793750 DL Status: VAL
Apt 1 Issue Date: 12/02/2008 CDL Status: None
City/State: North Liberty,IA 52317 Expiration 11/07/2013 CDL Cert None
Date: Status:
Endorsements: NONE CDL Med None
Status:
Mailing Address: 1605 North Jones Blvd Restrictions: Corrective Lenses Restriction None
Apt 1 Date of Birth: 11/7/1947 Supplement:
Mailing City/State: North IJberty,IA 52317 Sex: M
History Information
CLEAR DRIVING RECORD
Name: Burgess, Lester Vern JR DL/ID: 279AD3750
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:
VI lf,,% 6/6/2013
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(PI IOWA
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S,A Office of Driver Services
htifNa Iowa Department of Transportation
Name: Burgess, Lester Vern JR DL/ID: 279AD3750
6/6/2013