HomeMy WebLinkAbout13-020- r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
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Authorization Number % 3 — "ac)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Last
(Office Use Only)
2. Mailing Address q qt %7 v %fS�%2 � Cr�IQ+ IVet�e I J 22 41
3. Telephone: Home 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? i.l b
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? N U
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? V
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? ay
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)
ci�dnwad9 09/2012
I hereby certifythat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
LI-r';A r $ r� 6 . 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)
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Signature of Applicant U t Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by On this $T� day of
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).
Si ature of ori eChior designee
-5-/3
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.
Sign r� eicdt�erk or designee
Taxi cab businesses are required to provide Driver Identification cards.
S —
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
derlWadafi geapp2010.a 09/2012
CA
Iowa Department of Transportation
Office of Driver Services (Toll Free) WO -532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
1/24/2013
DL/ID #:
413AF8068 (IA)
Name:
Bodjona, Bassal Jean
Class:
D
Address:
941 22ND AVE APT 5
Audit #:
6640514
Restriction
None
Issue Date:
01/24/2013
City/State:
CORALVILLE, IA 522411549
Expiration Date:
12/31/2015
Endorsements:
3
Mailing Address:
941 22ND AVE APT 5
Restrictions:
NONE
Date of Birth:
12/31/1985
Mailing City/State:
CORALVILLE, IA 522411549
Sex:
M
History Information
Convictions
Customer #:
5597450
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date _C_o_nviction Date ACO Explanation County JUR
10/26/2011 '11/28/2011 IM14 ;Fall to Obey Traffic Sign/Slgnal 52 IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
10/31/2011- _ ._ - _ _ 654402 .._ IIA
Name: Bodjona, Bassai Jean DL/ID: 413AF8068
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:
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1/24/2013
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Office of Driver Services
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Iowa Department of Transportation
Name: Bodjona, Bassai Jean DL/ID: 413AF8068
Feb. 5.2013)
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Received jim,-4aj..28,-2013— 1:51PM--No, 1169