HomeMy WebLinkAbout18-031�+'� Ulrl®��1■
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1 82 6
(3 19) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. / 8 —b -qI
(Office Use Only)
APPLICATIOA OWFAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Failure to comlow
leI r t2 /tneauired" information will result in denial of the application
First Middle Last
1. Name (REQUIRED) [Jiff 5u -1g
2. Address (REQUIRED) 147131✓ijehfar y> --jyr/f
3. Contact Information (REQUIRED) Email: Cell Phone:
(All written communication sent via email)
recids�,onsU �1
4a. Driver's License expiration date (REQUIRED) 1-1-;3 9'
b. Taxicab Business Name (REQUIRED) Vl/&e4 oP C --l' ,-
5. Prior experience in transportation of passengers: 14 'r 1N#O r Cqb Q/, vi✓
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
T,
What happened to the charge? (Circle one)
Where
307-730,1 C"41
When
Convicted Dismissed Deferred Suspended P ad Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where When
✓ Fw1 k) Mw 'NAC,
What happened to the charge? (Circle one)
Convicted 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? _ V�s
Type of offense
Where
When
?'ca 1/¢ Il/17/iY
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).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
l
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
?SS Dt7Y9Vr/ issued on y-1 / expiring on I'y',2-S . I understand that if I
falsely answer any questions in this application, that this application 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 22,, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of ApplicanDate 3-9-/9'
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STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by S . I- ). 1I i on this q day of
S.
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 s license Ul-dll- ZGZ�
7 o5v9-17
Si.%re of Police Chief or designee 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.
Sigiiature of City Clary or designee
-9-/y
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
Gerk(TMIDRIVB GE PL92014am ndetl.DOC
MAR 0 g 1918
City Clerk
Iowa City Iowa
:�tlr3rS[:t
mar. 7. 1018, 8:14AM Div of Criminal Investigation No. 5130 P. 1/1
041V IILV ID nal.ra ,rnvrl Cab ffA)031A338upo r.uu21002
STATE OF
Criminal HistoryRecord
i �-
RequestPorm
q jm�
To, Iowa Division c(Crlminal Investigation
Support Operations Bureau, l" Irloor
219 E, 7° Street r
bm M011111 Town 50319
(515) 725-6066 '
(51$) 725-6080 Fax
on:
Gender
DCIA000untNumber:"- 9967-F
(if applicable)
From; Xellow Cab of Iowa City
P,O, Box 428
Iowa CIF, UA 62244
Phone; (319)338-9777
Faz: (319)'339-7302
0l-a'I-Fc I WN"le ElFeraale I
W4iver.ltlformallon: wltbout a signed waiver from the.subject of the regttest, a complgte criminal history record spay no
be releasable, per Code of Iowa, Chapter 692,2. For complete criminal hlstoryrecord information, a i gllawed by taw, always
obtain a waiver alonaturn cram of. ,.rm......... _
waiver Release: I hereby give pe miuina for the above requegang czahl to condos en Iowa criminal hlttdry record check with the DivisisN sJCY mind
Investigation (DCI). MyereninalAWay data annccming me the Vmalntelned by she Del may be relowed as allowed by law,
Waiver Signature;
r _ __— ,.-,,,, „�„•,vw .� vu�..-x� a� ua (DCI Use Only)
As of I a search of the provided name and date of birth rovaa)od:
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record at ed, DCI
Le ED
MY initials T M R O g
MIR
Cit
Received Time aar.�'1, 2018c10:33AM No.4864 towaCity, Iowa
/r Iowa Department of Transportation
I Office d DtiverSetvicas (Tdi free) b1121
PO Boot 9280, On Moines, IA BMW9200 515.2449124
0
FAX:515-239-1037
History Information
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
3/1/2018
DL/ID O:
255DD4944 (IA)
Customer it:
4329777
Name:
Williams, Clifford
Class:
D I
ID Status:
None
11/17/2014
Steven
D53
Non -Payment of
IA
IA
Address:
1015 W BENTON ST
Audit a:
1752853
DL Status:
VAL
APT 45
Issue Date:
04/18/2017
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
01/04/2025
CDL Cert Status:
None
522465116
Endorsements:
Chauffeur 3
CDL Med Status:
None
Mailing Address:
1015 W BENTON ST
Restrictions:
Corrective Lenses
Restriction
None
APT 45
Supplement:
Date of Birth:
01/04/1980
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522465116
History Information
Convictions
Citation Date
Conviction Date
ACD
I Explanation
Coun
JUR
01/15/2014
07/31/2014
M14
Fall to Obey Traffic
51 n SI nal
Johnson
IA
Sanctions
Type
Effective
End
ACD
Explanation
Occurrence
JUR
JUR
Suspended
11/17/2014
04/07/2015
D53
Non -Payment of
IA
IA
Iowa Fine
Name: Williams, Clifford Steven DL/ID: 255DD4944
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 &rur* teny, Iowa
this date: r
NAR 0 9 TO1B
CitY C/erk
Iowa City, Iowa
3/1/2018
R. a. T.
y� Office of Driver Services
Iowa Department of Transporation
Name: Williams, Clifford Steven DL/ID: 255DD4944
MAR 0 01018
City Clerk
Iowa City, Iowa