HomeMy WebLinkAbout13-119 .k Authorization Number /3 / 1
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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.,Illlonday—Friday.)
Iowa City, Iowa 52240-1826
319) 356-5040 )pe. .-
(319) 356-5497 FAX
First -Middle Las
1. Name\JR \(\/�l �,0n100 , )( I rl
2. Mailing Address 2Q3 C c .e. l
3. Telephone: Home ?\9- ia�' �< �- other:, )c) " Li-71 - (eLP ig
4. Prior experience in transportation of passengers: L 110
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 11116
Type of offense Where When
6. Have you 5n 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? ALO
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? LI6
Type of offense Where When
9. Have you ever plied 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 POUF 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 11114--)11
c ify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1 L 2-/ irtc j .' 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 _nd documents relating to this application, and I further agree that, if a license
is granted, to comply at/ I times with all of the,fovisions 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 Applicant IIk1?/' Date
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STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ,(a,c;rn,kit J . On this day of
May ani3
u SONDRAE FORT Som-111 2 F-
1= t Commission Number 159791 Notary Public in and for the State of Iowa
My rnmmiaci n Perinea
0 3/ 7 .14, 5`
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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).
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.
�g_ A} -
Signature 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/z"
(height)and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
clerk/taxidrivbadgeapp20l0.doc 03/2013
' May, 20. 2013, 3: 34PM Div of Criminal Investigation , No. 4107 ' P. 2 '
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Received Time May. 16, 2013 1 :37PM NIo. 3753
r3iIowa Department of Transportation
Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Moines,IA 50305-9204 515-244-9124
NvoloFAX:515-239-9-1837
Certified Abstract of Driving Record
Inquiry Date: 5/16/2013 DL/ID#: 434ZZ1669 (IA) Customer#: 4701536
Name: Johnson,]asmin Class: C ID Status: None
Monique
Address: 3509 SHAMROCK PL Audit#: 5989710 DL Status: VAL
Issue Date: 05/18/2012 CDL Status: None
City/State: IOWA CITY, IA Expiration 04/10/2017 CDL Cert None
522455137 Date: Status:
Endorsements: NONE CDL Med None
Status:
Mailing Address: 3509 SHAMROCK PL Restrictions: NONE Restriction None
Date of Birth: 4/10/1988 Supplement:
Mailing City/State: IOWA CIN, IA Sex: F
522455137
History Information
CLEAR DRIVING RECORD
Name:Johnson,Jasmin Monique DL/ID: 434ZZ1669
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:
e,'
.44 5/16/2013
t': IOWA 'y'
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D. O.T. lei
Office
�f DBIVE _- IowaDepartment fDriveServices
of Transportation
Name:Johnson,Jasmin Monique DL/ID:434ZZ1669
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This temporary document becomes f
invalid 30 days eRenssuance.
IOWA 1 YYRIV USA
M 1 1t 2• IIS Y�4 Er I t DRIVER LICENSE A
i1 i� { y/ {y8c x'' '°�,•i?//�?M 4y�f e'j4;afrA�< EI 4 (�{ } I..
CLASS:o-enaanear ' -. r3509'SHAMROC re
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ENDORSEMENTS: Commercial pass yen cit passenger I If you do not rece!ve �, IOWA CITY IA 52245
RESTRICTIONS; IfII rwrpermar.em 434721669
Licenuard2ldays,. EDL No. 4
please an ISS 05/16/2013 EXP 06/15/2013
1-800-532-1121 •
far assistance.. Cl D End 3 Sex F ys
NONERestrictions ] Eyes DRO J 4
01/10/19884allaTN^K ghfThC3 DOB 04/1 0/1 988
DO 663521318JJ1s14F1004170