HomeMy WebLinkAbout13-124 Authorization Number I 1 aq
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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 Middle Last
1. Name tl 1--cAt.c,l ) --)&•
2. Mailing Address 989 Bt S-- 7\1 A Q,1 i/'t 5,2 30
3. Telephone: Home 319 56-0 E G 5 7 Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /
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? ./✓
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? A
-
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? "10
Type of offense Where When
9. Have you ver 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)
clerkltaxidrivbadg 03/2013
I hereby certiIN at I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
3E) I L) . 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�ti� Date / , i
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by M. -eh-t// -8ti Z . On this !o day of
-duIv4 ao/
o tis SONDRAE FORT
Commission Number 159791
r
My Commission Expires Notary Public in and for the State of Iowa
945,7
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.
• ---4(4.,7
Signa re of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/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
Iowa Department of Transportation
`• Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 6/5/2013 DL/ID #: 127888143 (IA) Customer#: 4563536
Name: Butz, Mitchell James Class: D ID Status: None
Address: 989 8TH ST Audit#: 6989889 DL Status: VAL
Issue Date: 05/30/2013 CDL Status: None
City/State: MARION, IA 523022918 Expiration 08/14/2015 CDL Cert None
Date: Status:
Endorsements: 3 COL Med None
Status:
Mailing Address: 989 8TH ST Restrictions: NONE Restriction None
Date of Birth: 8/14/1990 Supplement:
Mailing City/State: MARION, IA 523022918 Sex: NI
History Information
CLEAR DRIVING RECORD
Name: But; Mitchell James DL/ID: 127888143
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:
'�VEKICLf "v,
:• �7G/Jit 6/5/2013
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Iofficowa of Driver
rtme DepartmentServices Transportation of
Name: Butz, Mitchell James DL/ID: 127888143
' State of Iowa .„---:13-0?--4
1�NS OF�PU lei Division of Criminal Investigation ��pit: ; * ii s.
,a�Q(�� Z1` 215E7r"Sty/ , ter"}
" "� IOWA Des Moines IA 50319 ^"' ""'" a.a
�\o\L I Cc�y Ph.515-725-6066 Fax 515-725-6080 EY R• *•."� 4, S
C r/NINO
\Stir p`t4, Iowa Criminal History Record Check II pt -
Walk-In Request
Your name P1A-,bv.4I ,) 13,-12—
Address 9S 9 8i 11 5+
City/State/Zip St , nr> , 4 /.7-- 3 c2 Fill in all shaded areas.
Phone# --- 19 s o g,‘ 4 7
Requesting an Iowa criminal history record check on:
Last Name Apellido(mandatory) First Name Primer Nombre(mandatory) Middle Name Segundo Nombre(recommended)
Lav iz M 1-}L(41-•! I a%rne,
Date of Birth Fecha Nacimienro(mandatory) Gender Genera(mandatory) Social Security Number(recommended)
g/i 11/90 ErMale OFemale (1 72 -12- 100q (-1
Waiver Firma(If the request is on yourself,please sign. If the request is on someone else,write N/A.)�
Results //
DCI USE Omv
As of U b\13 , a name and date of birth check revealed:
No record found
u
['Record attached, DCI#
DCI initials c
Receipt
Number of requests I x $15.00 per last name=Total amount$ t 5. 0 0
Method of payment: %leash Omoney order Ocheck# ['MasterCard or Visa
Cardholder's name Last 4 digits of MC or Visa
DCI initials
Credit Card Number# Exp. Date