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Home My WebLink About13-098 Authorization Number I-27`g$ 1 (Office Use Only) '.Zig®fid -s, „,„„,...,:qr ....„.......______ 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 /I )) /Middle Last 1. Name GGA r, s7Y,!�het'- C Gtci r le_S 13-e-_,I, -t 2. Mailing Address /? C. /f S]fireG f-- ~J 3. Telephone: Home 3/ ' 33Y (2 W. Other: 4. Prior experience in transportation of passengers: /0 j,P 4)-s 7`�,4-, 4,,-✓cr C, 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /4/c, c, 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,j Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? ,; Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /4/0 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) A/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) clerkltaxidrivbadg 03/2013 v I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number ln/k-,./ 95'36 . 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 Date U3 v/3 STATE OF IOWA COUNTY OF JOHNSON ) J Su.scribed and sworn to before me by C-/1 i'i 5 4 Le4/ c arkS if n On this day of • lam Notary P lic 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). X�✓ / 3 ignatu 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. �yrm /(1 . tom✓ vim' 3 - l3 Signa of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/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 clerk/taxidrivbadgeapp20l0.doc - 03/2013 v as As, uio 2013 4:22PM Div of Criminal Investigation Del IOWA 8950 Plei UVa • STATE OF IOWA :::`... "'c ,....:... .!.; 40 Criminal History Record Check Request Form `• :, '.. /r. h• �1 r, ,uV DCI Account Number: lira`PC- �I1f1 �^ LI"Sable) TM lows DMsionofCringed inventioltua " Prom: IN\Mp9 10.X( suppoROpwtloca Duren.Id Floor 14 S I GvrMt Or 213 C 7°Skeet Dee 15)715a,Iowa 50319 141/415& � I A 5344 (Sl3)723iaf6 , (srsl72stoso Fax (314./ 33>t- VPI' Phone: i Fan,. (31q S41-15a99 1 nm requesting an Town Criminal IilstoIXRecord Check on:• • •- Lot Name Naame tmcdsmry) Flinn Name(,,s,.wsy) / Middle Name(recon n,wea) Be./✓ lr•gg � ) C� ylit-ii-i-o Ae. (. C.---'41 I-Ay Date of Birth(m,drmm Gender(awdamy) Stic1al Security Number¢®mmenam Arr,i 30 /965 Male OFemale ,1756187 3y Waiver Information:Wltbout a Ugnd waiver from the subject ofthe request,a complete whatnot history rcooed may not he r.lniable,perCodi often,Chapter 6P2.2.For comnim¢Amoralhistory recoS lerortatlon,as allowed bylaw.always Obtain a waver slaoamre hoal lhs subject of the ramal. Waiver Release:Moray drapemWlen O r S em,vm alma omew to=ductaolouvatmbW Wray,mom ohm%wit da DM!im attdmteet rn.mapdaa pea my ethane Wwty 41e meaning ma r sburad by drDU maybe*ad Al snowed bi trw • WaiverSignarare: Ci-e.y,---ev,---' Iowa Criminal Ristory Record Check tomtits (sham only) As of -k 14-13 ,u search of the provided name and date of birth revealed: ;.i : .i - ® No Iowa Criminal History Record found with DCI 0 Iowa Criminal History Record attached,DCI tl •• • I DCI initials Ili) I Ni DCI-77(06123/10) Received Time Apr. 1. 2013 11: 12AM No. 8857 4 elova Department of Transportation .9,r Office of Driver services (Toil Free)800-532-1121 PO Box 9204,Des Maines,!A 50306-9264 515-244-9124 NielFAX:515-239`1837 Certified Abstract of Driving Record Inquiry Date: 5/3/2013 DL/ID #: 005WW9836 (IA) Customer#: 4138394 Name: Bergin, Christopher Charles Class: D ID Status: None Address: 1920 H ST Audit#: 5996854 DL Status: VAL Issue Date: 05/22/2012 CDL Status: None City/State: IOWA CITY, IA 522402029 Expiration Date: 04/30/2014 CDL Cert Status: None Endorsements: 3L CDL Med Status: None Mailing Address: 1920 H ST Restrictions: NONE Restriction None Date of Birth: 4/30/1965 Supplement: Mailing City/State: IOWA CITY, IA 522402029 Sex: M History Information CLEAR DRIVING RECORD Name: Bergin, Christopher Charles DL/ID: 005WW9836 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: w.q` st-...-- '.74l/ 5/3/2013 0 ' IOWA *'ti • Ilr �i1 e of D river Services" ,Bj -8 , SIowa rtment of Tansportation Name: Bergin,Christopher Charles DL/ID: 005WW9836