HomeMy WebLinkAbout14-057 Authorization Number
1 (Office Use Only)
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CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER
(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 Last
1. Name LU/S C20 S Tgud I T6-
2.
6-
2. Mailing Address 4/13 6-141 4ve Qp 5
3. Telephone: Home ('- C-'1) L4 0 0 • j ci Other:
4. Prior experience in transportation of passengers: y\fc)Yl
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? jl C
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? y(D
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? P,c)
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 0 (.:
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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
clerkitaxidrivbadg 03/2013
Authorization Number
1 (Office Use Only)
izia"Abb.CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER
(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 Last
1. Name LI/LS /1 CIZo s Tr-1cJ'l/ T t
2. Mailing Address //3 v[ Ove 4,p-1
3. Telephone: Home (31c-\) L0 O "5(1-73-7 Other:
4. Prior experience in transportation of passengers: v
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 11 C
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? yt C�
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? L�tri
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? t- C
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)
t'1,
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)
clerkNaxidrivbadg 03/2013
Feb. 28. 2014 11 : 56AM Div of Criminal Investigation No. 4091 P. 5/7
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,w xiti STATIC OF IOWA ;. +0:104.
if,i �) Crriita nallHistoryRccorrd (Cheek ` b.%,3.. i;" ,
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To: Iowa Division of Criminal Investigation From: City of Iowa City
Support Operations Duroau,lieffi•Ioor City Cierlt's Office
215 E.7a'Stceet 410 S.Washington Street
Des Mein es,Iowa 50319
(515)725-6066 Iowa City, XA 52240
(515)925-6080 Yax
Rhone: 319-3S6-5041
Cb- •
Fax: 319-356-5497
lam requesting an Iowa Criminal�istoly Record Check on:
Last Name(naandalory) First Name(maudatoy) Middle Name(rcrolemenard)
CDS1 000 V\ , Lo\ S j
Date of Dinh{mandatory) • Gender(mendetory) l Social Security Numb or(acmmended) .
2-' 2.1t 9 62.1 (Mala °Female 6, D " C) 't"`� IG
1
Waiver II brinallon:Without a signed waiver from thosubJectofthe request,a complete criminal history record may not
be releasable,per Code oflowa,Chapter 692.2.For comuletQ criminal history record information,as allowed by law,always
obtain a waiver signature from the subject of the request.
)R1peP RelenSe:thcrebyg'nopermissionfrr the above requcsling ofnolal to tended an Iowa erintlnal hlsItaymc rd die&with the Division of Criminal
lnvesllgerlon(DCA. Any cdsnioei bisrory data oneenung me dud itmeinmi cd by1 e,be released as allowed bylaw.
Waiver Signature: P , 1—
Iowa CriilinaY k4[i��oxy l'eco>rad rC�aecis�8 UI (DCruse only)
As of 2-caCo-'/1/ ,a search of the provided name and dato of birth revealed: _
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No Iowa Criminal History Record found with DCT r i
cf,ti, ry .,r=:
0 Iowa Criminal History Record attached,DCI# r;
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DCIinitials_�� r— ---
Received Time—Feb. 24. —2014-12:52PM—No. 934 -
•
-.. Iowa Department of Transportation
Office of Driver Services (Toll Free)800-532-1121
PD Box 9204,Des Moines IA 503059204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 12/12/2013 DL/ID#: 609AH7197(IA) Customer#: 5988796
Name: Crosthwaite, Luis H Class: D ID Status: None
Address: 413 6TH AVE APT 5 Audit#: 7603641 DL Status: VAL
Issue Date: 12/12/2013 CDL Status: None
City/State: CORALVILLE, IA Expiration 02/28/2017 CDL Cert None
522412340 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 413 6TH AVE APT 5 Restrictions: Corrective Lenses Restriction None
Date of Birth: 2/28/1962 Supplement:
Mailing City/State: CORALVILLE, IA Sex: M
522412340
History Information
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•
Conviction's:-. i' r ,; , ,. '
•
Citation Date Conviction Date ACD Explanation County JUR
10/09/2013 11/26/2013 fM14 frail to Obey Traffic Sign/Signal :Johnson hIA
Name:Crosthwaite, Luls H DL/ID: 609AH7197
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 isa 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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12/12/2013
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k MO Iowa Departure t of'Transportation
Name:Crosthwaite, Luis H DL/ID:609AH7197