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Home My WebLink About14-092 Authorization Number I y- _ 1 (Office Use Only) 471:7".441 147, APPLICATION FOR TAXI/MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First Middle / L st 1. Name 77; it -e_ r n , - Ir Y\ 2. Mailing Address c7_2 5'74, 3. Telephone: Home (-31?:„,), 3 E f / 2:2, Other: Ce %/( /!) _5:5-7- 6 2 4. Prior experience in transportation of passengers: r. i 1'-e Y >i� UC 47;vim. r // r I ern c S 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? lD 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 o Type of Offense Where When 1 7. Have you been convicted of any traffic offenses in the last five years? Ye S Type of offense Where When T� I e .-<1 ,v&( w,��--�x� , /—/ -77r oc-- e i rS J Q N at-S ,f3�hfi o n e o v rCtkj ,2 $- / 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /Y t• 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) A/CD 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) cleNtaxidrivbadg 03/2014 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number Lf 1 g V v 9.3 9 9 . 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) Signature of Applicant Date -2- JL/._J 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. *********...*******************************Int*********YrIr************************************Irk*********************************************** STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by --re{ c. ) 6 . QTY ntl�� . On this I `- day of A,\c l as ly WENDY S.MAYER . • � — • � ,,a} t Commission Numbe 729428 Notary Public i and for the Stat: 'f Iowa i 1C13m.ission1lQ Aires iow l 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). Signatur- of Poli - 07 ief 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. . 4-E2if,d27Z /_J /V Sign e of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/2" (width) and 5 1/2" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update clerWtaxidrivbadgeapp2o74.doc 03/2014 ��t of Pi, ,y4p�f OF ro�T,s `it- - s STATE OF IOWA _, '°`"" Criminal History Record Check .`_ ,' 4 i`' Request Form CAr • y^ Ol — ''p t; 9•. MIN„ st snow p��_; r _ o` DCI Account Number: 9861-F (if applicable) To: Iowa Division of Criminal Investigation From: .City Clerk's Office Support Operations Bureau,1 Bureau,e Floor 215 E.7th Street City of Cedar Rapids 101 First Street SE Des Moines,Iowa 50319 Cedar Rapids,IA 52401 (515)725-6066 (515)725-6080 Fax Phone: 319-286-5060 Fax: 888-966-0171 I am requesting an Iowa Criminal History Record Check on: -N — ,Last Name;(manry)= z lElrst Nem oai sj 1VlidlleFNae Laadao�, r 4 iet r t,r�.4" �[' � r a_ m mss_ s _— ba of th(maoa oryj=rte„ . taatar r a ocla to - l$ecun N er manaa<ory)T - > ?Y a kra Female_ e _nom_- -a 1— • tW Ne InforrnahOli`Wrthou a sig drwarverfrom,the sublecc oft1re quest,a ecoomp7enmmaIiustcry curd'maynot 1 b�rFeleasable;_pe irre ac of ova,Chap a .For complete cnmwal-theory,r_ra mf rli a alloyved lirlag Wynn ob _ _ obfam a waAver srgna u�re from,,he'snblecfofllie•re- 'quest—� - � = _-� tWarvei5R e I berebx�ve perm W6rior we above requesting officiZ to conduct ani a criminal lastary record cbedcwrtfiffie v son of ithinal_ W:H- --- --n-DCI1=AnXtnm-tmc-t --q,- once getbaf r--- eDC---ct--r a-=-4,-wed6ylaw � . _ ,=- = } =a_a � 'kms,c �. - _ - :=T -74 - zys Srgnar_ce`__ - irri Datett • Iowa Criminal History Record Check Results (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) PLEASE MAKE ADDITIONAL COPIES AS NEEDED. „Thr-r, G (7Q' - T) 3 -f-771 IA- SING Page 1 of 1 Single Contact License & Background Check „ \ Results • Criminal Histo Background Check Last Name Other Last First Name DOB SSN Name Selection Blackbourn Terrell 1945-November-10 389464063 Criteria Results Not found in Database Background Check Complete As Of 3/10/2014 3:58:39 PM NOTE: The first and last names, date of birth, and SSN displayed in the abuse registry and criminal history results are just as they were entered on the screen. Billing Account 9861-F Cash Deposit Currently at$1604.00 Generate PDF _-Search_Again-- ..:_ httes://www.iowaonline.state.ia.us/SING/SINGSQLProcess.aspx 3/10/2014 S572. Source: DLR Dest : S572 S572. WARNING: DRIVER'S LICENSE AND NON-OPERATORS IDENTIFICATION CARD INFORMATION AND PHOTOS ARE PROTECTED BY THE FEDERAL DRIVERS PRIVACY-PROTECTION ACT (DPPA) (18 USC 2721 ET SEQ) . BY CONTINUING; YOU AGREE THAT YOU WILL COMPLY AT ALL TIMES WITH THE DPPA, WILL ONLY ACCESS AND USE DL AND ID PHOTOS AND INFORMATION FOR LAW ENFORCEMENT PURPOSES IN THE COURSE OF YOUR EMPLOYMENT AS A LAW ENFORCEMENT OFFICER, AND WILL NOT REDISCLOSE ANY DL OR ID INFORMATION OR PHOTOS UNLESS PERMITTED BY THE DPP&. CONSULT YOUR-AGENCY OR AGENCY'S COUNSEL FOR - —DIRECTION ON 'PERMITTEI!REDISCLOSURE AND RECORD KEEPING REQUIREMENTS.- ***PRIVATE*** OLN/418VV4399 SOC/389464063 CO/LINN NAM/BLACKBOURN,TERRELL EDWARD RES/922 7TH ST SW CEDAR RAPIDS,IA 52404 MAIL/922 7TH ST SW CEDAR RAPIDS,IA 52404 DOB/1945-11-10 WHITE MALE 510 155 EYE/BLUE LEGAL PRES/U PENDING ACT/ CDL STATUS/ NCDL STATUS/VAL CLASS/D ENDOR/3OTHER RESTR/ 255/2013-10-24 EXP/2018-11-10 AUDIT/7465669 AKA/BLACKBOURN,TERRELL E AKA DOB/ PREV DL/IA 389464063 PREV SOC/ DATE TYP DATE/FILE JUR EXPLANATION 2014-02-28 CON 2014-03-10 IA FAIL TO OBEY TRAFFIC SIGN/SIGNAL 2014-02-28 ACC 792323 IA 2014-01-31 CON 2014-02-10 IA FAIL TO OBEY TRAFFIC SIGN/SIGNAL REQUIREMENTS TO BE SATISFIED: ELIGIBLE TO APPLY: YES ********** END -OF RECORD********** .. __ _ .. ;201404071458/201404071458 S572 290 MESSAGE FROM DLR 130263