HomeMy WebLinkAbout13-050.0.— -4
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
Authorization Number /3-50
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
First Middle Last
1. Name i
1
2. Mailing Address -r A c �1 sA S�Ln
�SSZ _amu.
3. Telephone: Home 3 Other:
4. Prior experience in transportation of passengers: ja4r
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Aro
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? Gln
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? n
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ..,
Tvoe 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)
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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derktmdnw 6g 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
n 12A A It. I understand that if I falsely answer any questions in this application, that this
application may bed nied. 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 11j,;&A�p Date n3—OI-1�
r
STATE OF IOWA )
COUNTY OF JOHNSON )
Sub d ancV'swo to fore me by I- le Jt— A/ G( t-[ t On this 1 `S� day of
r
]KE: K. TUTTLE Notary Public in and for the State of Iowa
-. E:E on um er
V way Com issi ices
)Ax
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).
Signaturd of Polio ief 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 ure of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
3-/-i3
Date
cien idnmad�pp2010d« 09/2012
CIowa Department of Transportation
AO Office of Driver Services (Tall Free) 800-532-1121
PO Box 9204, Des Niones, IA 50306-9204 515-244-9124
FAX_515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/26/2013
DL/ID #:
012AA1684 (IA)
Customer #:
2975544
Name:
Nguyen, Hien Thanhthi
Class:
D
ID Status:
None
Address:
2557 INDIGO DR
Audit #:
4517286
DL Status:
VAL
Issue Date:
07/15/2010
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
02/01/2014
CDL Cert
None
522406824
Date:
Status:
Endorsements: 3
CDL Med
None
Status:
Mailing Address:
2557 INDIGO DR
Restrictions:
NONE
Restriction
None
Date of Birth:
2/1/1971
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
F
522406824
History Information
CLEAR DRIVING RECORD
Name: Nguyen, Hien Thanhthl DL/ID: 012AA1684
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:
�..•""••:
2/26/2013
D10 '�
D. O. T..*-* •
'
�'
Office of Driver Services
Iowa Department of Transportation
Name: Nguyen, Hien Thanhthi DL/ID: 012AA1684
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