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HomeMy WebLinkAbout18-055 IDENTIFICATION NO. j S 11 r 1 (Office Use Only) gla '1'.°0.41 APPLICATION FOR TAXICAB/MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m.to 3 p.m., Monday-Friday) CITY OF IOWA CITY 410 East Washington Street Failure to complete the "required"information will result in denial of the application Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) Hec +J— ""7-1-1CDroC 5 WQ 622'1/0 2. Address (REQUIRED) 2 8o I VsiY _ ,3? -l-©WQ C- A 3. Contact Information (REQUIRED) Email: .5l �• .• - _� � ark o o• Cell Phone...�J�9 9� (All written communication sent via email)CcDrn ' 4a. Driver's License expiration date (REQUIRED) 57.117pt S b. Taxicab Business Name (REQUIRED) 1 P I f o,,,, a-owQ C 1-.17 5. Prior experience in transportation of pass n ers: I ea - - - ilk 010 y 1�s i is 411/ Ye 11140 w Ccs rPP r�c e4 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? /V p Type of offense Where When W a m C --� t i 2 < N e T<a 3 171 What happened to the charge?(Circle one) �• r.3 ID Convicted Dismissed Deferred Suspended Plead Guilty Other, 7. Have you been arrested/charged with any traffic offenses in the last five years? Yes Type of offense Where seed LI >7im C _ 7 '7 P 2 o 1 3 . a . 6�. s- -13;1--) 0 1 2 7 2 1 s 1-9?happen to fie c�ia je?( 1rc►-r'i bne) I •— tJ o h h Sc.r-) Cis 21 2 Q 1 8 Convicted Dismissed Deferred Suspended Plead Qpilty Other C7 8. Has your driver's license or chauffeur's license been suspended or revoked in the - /I'- years? N y p Type of offense Where When 9. Haveyou ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) C, (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 APPL!CATION FOR TAXICAB VEHICLE DRIVER Page 2 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). I hereby certify that I h ve iss ed to me by the Iowa Depart ent o Transportat. n a valid Driver's license number 76, 9 Y 1 Q 3 issued on�j-12 2 ing on / E I understand that if I falsely answer any questions in this application, that this applica on may be denied. agre 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 Cit. Code. Needs to be signed in front of a Notary Public) Signature of Applicant % .4110 Date 2 1/2 01 *****************A AAAA**** ************#*FM*** AAAAA..***********k* ...A *************** STATE OF IOWA COUNTY OF JOHNSON ) 1 N 4, Subscribed Subscribed and sworn to before me by —71-\ c w �- , ���� oo_this day of _) N tart'Pu lic in and for the State of Igwa.: IN" C ***************************************************************************************************************** **rxil4*****fr*********** I have reviewed this application, DCI report, and the State certified driving record of this applicant and havezdetermined 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 date of Driv: ' -i .- - 7 -- i7 C-Z. l Sign44 - 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. SiOnature of City Clfric or designee Date Office Use Only Approved application DCI report State certified driving record Website update OerIVTAXIDRIVBADGEAPPL9201 Bamendetl.DOC 04/2018 May. 17. 2018 1 : 38PM Div of Criminal Investigation No. 1747 P. 1/1 05/14/2018 15:25 Yellow Cab f 43193382708 N.uu21002 STATE OF IOWA •'r E';Zjil ' .A.:'.,',1 Criminal History Record Check . tf:_,--.'its,:-...:4:,aF„ �8r,. Requestortn r.:: ' no Account Number: 9967-F (if applicable) To: Iowa Division of Criminal Inveatlgation From: Yellow Cab of Iowa City Support Operations Bureau, 1”Floor P.O. Box 429 . 215 E. 7"Street . • • Des Moines,Iowa 50319 Iowa City,IA. 52244 (515)'125-6066 • (515) 725-6080 Fax - (319)338-9777 . Phone; Fax: (339)339-7302 • _ - I am re a ueatin: an Iowa Criminal Histo Record Check on: . Last NA Me (marrtluory) First Name(.nd.tory) .. Middle ime( a,a dl s . ea `lT��'1orr0 t iti r. �". _ r Date of ;• h (mmaetory �.__. Gender • �• r � � �, (mandatory) . oCiaJ_Sec _,,, .\ :,ber�rttd _ 5" x , 17 5- �']' �- , N Male Female I C/-72' , SS i . Waiver Information:Without a signed waiver from the subject of the request,a complete criminal history record way not'. be releasable,per Code of Iowa, Chapter. 692.2.For complete criminal history•record Information,as allowed by low,always' obtain a waiver si:nature from the sub eat of the re.uest • • Waiver Release:I hereby glue permission for thb above requesting official to conduct an Iowa criminal history rcootd ch- with the Division of Criminal': Investigation(DCI), Any cf,minel history data aenocrning me that I maintained by the Del may bo -, lowe4 ' lyralver Signature: Y jam., -. ,,110 T Iowa luminal History Record CJeck Resul' S (DCI use only) As of " i� , a search of the provided name and date of both revealed;.., No Iowa Criminal History Record found with DCI . •... . . _ Cr_ , . ; 0 Iowa Criminal History Record attached, DCI -• � DCI initialsAC-- • u . DCY-77 (08125/10) . o.,,, ;,,.a T;.... M,,, 14 111lll 1. 1KPM N„ RR11 . • • 6) 10WA DOT Sl�ShHIEk I Slht('EEk I CUSiOh!ER DRIVEN www.iowadot,gav Driver&IderitOcatian&wins PO Ws'RIM I Des Wain.IA!pI) KI-14 rfleflP '1'744' 1.74 1 Fax 5I!-7 -IfOrr Certified Abstract of Driving Record Inquiry Date: 5/14/2018 DL/ID#: 769YY6103 (IA) Customer#: 915880 Name: Heath,Thomas Class: D ID Status: None Edward Address: 2801 HIGHWAY 6 E Audit#: 1807951 DL Status: VAL LOT 394 Issue Date: 05/12/2017 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 05/19/2025 CDL Cert Status: None 522402658 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: 2801 HIGHWAY 6 E Restrictions: Left and Right Restriction None LOT 394 Outside Mirrors, Left Supplement: Outside Mirror Date of Birth: 05/19/1959 N Mailing IOWA CITY, IA Sex: M City/State: 522402658 cz) History Information O cn. Convictions �v b ' rn 1 1 "� N Citation Date Conviction Date ACD Explanation County - jtl?t 07/07/2013 07/18/2013 S92 Speed Linn ="IA r, 12/27/2015 01/27/2016 M14 Fail to Obey Traffic Johnson IA Sign/Signal 01/21/2018 01/31/2018 M14 Fail to Obey Traffic Johnson IA Sign/Signal Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 06/29/2017 990365 IA 11/30/2017 1018334 IA Name: Heath,Thomas Edward DL/ID: 769YY6103 Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver&Identification Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by Driver&Identification 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: 4.0,HT IA r ,,r,� 5/14/2018 ,-10111110) deeyez-1 Qp fiG y Driver&Identification Services C' L DULLS Iowa Department of Transporation Name: Heath,Thomas Edward DL/ID: 769YY6103 n� N rn 3 r�.