HomeMy WebLinkAbout13-039� l 1
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CITY OF IOWA CITY
410 East Washington Street
owa 52240-1826
(319)3S6-SO40
(31 -5497 FAX
.. First .
1. Name
2. Mailing Address L U W
3. Telephone: Home 31°1 `j S (o
4. Prior experience in transportation of passengers:
Authorization Number (SI -32
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Middle
Other:
Last
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /I/6
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?/\10
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? //0
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? A1,9
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)
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)
denne"dnwadg 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number*N
(03 MQ�r{ 2(0(� 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) n 1-,--,7
Signature of Applicant Date 2 2 G✓ Zvi 3
STATE OF IOWA )
COUNTY OF JOHNSON )
�4S on Iti
Subscribed and sworn to before me by 54�.��\ ��vr\ 1s�{'o�� � . On this day of
�
��lotary P plic in and for'
the Stated 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).
Signature of Po ice Gbfef 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.
Signature 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
Date
derW9axi wbMg.pp2010.G 09/2012
f
i
Iowa Departmentof Transportation
j Lice of iirhw SeMms (Toll Ffee) 800' 532.1121
PO Box 3208, des Moines, lA 503D5-02(14 515-244-9124
FAX:515-239-1837
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Certified Abstract of Driving Record
JUR
Inquiry Date:
1/29/2013
DL/ID #:
631MM4266 (IA)
Customer #:
4942146
Name:
Thurston, Samuel
Class:
D
ID Status:
None
Jason
Address:
2505 WAYNE AVE
Audit #:
6651912
DL Status:
VAL
Issue Date:
01/29/2013
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
12/06/2017
CDL Cert Status:
None
522402523
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2505 WAYNE AVE
Restrictions:
Corrective Lenses
Restriction
None
Supplement:
Date of Birth:
12/6/1977
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522402523
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
I Case Number
JUR
102/25/2009
496581
IA
Name: Thurston, Samuel Jason DL/ID: 631MM4266
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:
'tlF�'lf `Niil 1/29/2013
IOWAY�
Office of Driver Services
Iowa Department of Tmnsporation
'Feb.21. 2013 3:12PM Div of Criminal Investigation No -4140 P. 3/5
Feb. 12. 2013 12:59PM City Clerk — City of lora City No -3217 P. 2
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