HomeMy WebLinkAbout18-028CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 5 22 40-1 826
(319) 356-SO40
(319)356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO.
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
3. Contact Information (REQUIRED) Email: Q c, I Ia.c\T 0 I4, i�, Y 4 -i,) owl Phone: f) -32-A -)4_p-
(All written communication 3'erit via emal)
4a. Driver's License expiration date (REQUIRED) 7/ ? Q1 :0LZ
r—�
b. Taxicab Business Name (REQUIRED) ye Ila V1 t2L 1rj t -i" r_4-1
5. Prior experience in transportation of passengers: T ✓ fl 14p/nr^5rA 011 4:C' XI\ )J rI\v er
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
VV i iat 110PPai rou LU it le unarge r tl.Ircie one)
Convicted Dismissed Deferred Suspended
Plead Guil
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
Where
Other
When
What happened to the cha '> Circle one)
Convi Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? NO
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)
Ilk r'\
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).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that Dave issued to me by the lowapepartment of Transportation a valid Driver's license number
:7i Cel a;7_n j (L IiC M!G6 q issued or Z_1fc, / y rj;xpiring on 7/90/1J]Z. 1 understand that if I
falsely answer a y questions int is application, that this appnca on may 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 authorization to be a taxicab driver 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 U ld
STATE OF IOWA )
COUNTY OF JOHNSON )
PAO
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration d of r' nse
�'f 7
Si lure of Police Chief or designee
0?-30-ZC,z2
a -ZB /p
Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Signature of City Clerk or de ' ee Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update
QeMnAXIDRN94DGEAPPL92014e ded.DOC 07/2016
Feb. L/. Hid IM: AM Div of Criminal Investigation No. 4736 P. 1/3
From:Cl[y of Iowa City Clerk Offleo 310 OSS6407 02/22/R018 16:38 0403 P.002/002
STATE OF IOWA
Criminal History Recoid Check
Request Form
F:.
To: Iowa Division of Criminal Investigation
Suprort operations Bureau, V Floor
215 E. 7" Street
Des Aloins, Iowa 50319
(515)725-6066
(515)725-6088 Fax
I am requesting an lowa Criminal histo Record Check on:
7 - 3r)—
DCI Account Number: t!.o 2 'p
litapplicablc)
From: Cit oflowa Cites
City Clerk's O15ce
410 P. Washington Street
Iowa City, IA 52240
Phone: 319-356.5041
Fax: 319-356.5497
❑Female
v,5 e
�Ailafilil�
WatperXnjormnflort. Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2, For spropletle criminal history record loformalion, as allowed by law, always
obtain a waiver sigaeture from the subject of the reaaeat.
Waiver Release: I hueby give pumission for the above scqucaaog official to eoadou an tows criminal history record check will the Division oPCr urinal
InvteOgation (DCq. Myciiminel history dale ranecmive that is meInfained by the IDCl may be rdeasedgc.eliowed by hw.
--a"aaauu+1 101.V1 imuvUru unecKKesultS
' � (DCI use only)
As of a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
® Iowa Criminal History Record attached, DCI #
DCI initials
DCI -77 (08/25/10)
a TI... 1.t 99 91110 A.IIDht hl„ d6n7
Iowa Department of Transportation
0 dice d Mi6w ftVkm (rdi Ftee) 800.532.11121
PO Ow SM, Des Wings, lA SMDCr9204 5152444124
FAL' 615239.1837
Certified Abstract of Driving Record
Inquiry Date:
2/22/2018
OL/ID #:
Name:
Jackson, Dallas
Class:
8858609
Joseph White
VAL
Address:
920 N GOVERNOR
Audit #:
07/30/2022
ST
None
Chauffeur 3
CDL Med Status:
Issue Date:
City/State:
IOWA CITY, IA
Expiration Date:
522455920
07/30/1989
Endorsements:
Mailing Address:
920 N GOVERNOR
Restrictions:
ST
Date of Birth:
Mailing
IOWA CITY, IA
sex:
City/State:
522455920
Convictions
230AD2948 (IA)
Customer #:
5386301
D
ID Status:
EXP
8858609
DL Status:
VAL
02/19/2015
CDL Status:
None
07/30/2022
CDL Cert Status:
None
Chauffeur 3
CDL Med Status:
None
Corrective Lenses
Restriction
None
Supplement:
07/30/1989
M
History Information
Citation Date
Conviction Date
ACD
Ex lanation
lCounty
3UR
12/02/2015
01/05/2016
F34
Stopping on
Traveled Way
Johnson
IA
Name: Jackson, Dallas Joseph White DL/ID: 230AD2948
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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:
2/22/2018
�.�D . 0, T
Office of Driver Services
-- Iowa Department of Transporation