HomeMy WebLinkAbout18-062 r .. ,
r IDENTIFICATION NO. 1.E3-0 LQ,c: -..,
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(Office Use Only)
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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
4 I 0 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) ./1/) el,- ,.,-,4 4-4e (..., ,
2. Address (REQUIRED) ?cS 76 (oca ( (Pc ,r71 4 / i ( ,ra JI/,"/9 ,
3. Contact Information (REQUIRED) Email: -1.--R.Zn/ -Oo/f6 Q/y/ IASA J Phone: 3/y -519- 7 d/5
All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) /e/'EoZQ 2 3
b. Taxicab Business Name(REQUIRED) aAt)7"// 71 .2
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5. Priorr experience in transportation of passengers: .� I 1 _ G'' // 4 `
6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere'? �`
Type of offense Where When
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What happened to the charge?(Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested/charged with any traffic offenses in the last five years? /2
Type of offense Where W -n
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What happened to the charge?(Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license bee uspended.or revoked in the last five years?
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Type of offense ,�j ere
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9. Have you ev rlied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
11
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
04/2018
APPLICATION 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 hat I h ve issued to me by the Iowa Department of Transportation a valid Driver's license number
is;— j issued on .2174,4/ expiring on2
Y�I �� / jr?/7DZ 5 I understand that if I
falselyanswer an u tions in this application, that this application may be denied. I afree that in Making PP 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 , Chapter 2, of the i Code. (Needs to be signed in front of Volotary Public)
Signature of Applicant /1..____--1 / Date j/ Z�j Y i t
/ v CCC /// ���7—{ --
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+*************************+********** ******************************************************** *+
STATE OF IOWA )
COUNTY OF JOHNSON ) —}
Subscribed and sworn to before me by S/��p C ",f _ on this F) day of
,'tom . De .
ria NERDY S.MAYER 26 Notary bli+i and or the State o Iowa
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***** ***********************************************************t********************************AAAAA*******************AA A A A AA A.
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 date of Driver's .se /Z. - 36- ZU z1
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Signature o ice 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.
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Signature of City Clerk or designee Date
**************************************** *******************************************************************************************+***
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Clerk/TAXIDRIVBADGEAPPL92018amended.DOC 04/2018
,
Jun, 26• 2018 8:49AM Div of Criminal Investigation No. 5216 P. 1/1
�vrccrav to r 1:Ilir vuvvl Calf (FAV1933bciuo 1-.1.02/002
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:. ,..".:,\ 1, STATE OF IOWA • , 1t. ,;<<r
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Crlininal History Record Check , . �, `,, or or g .
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r DCX Account Number: 9967-F
(if applicable)
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•
To: Iowa Division of Criminal Investigation
Support Operations I4ureau, I"Floor Protta: Yellow Cab of Rows City
215 E. 7`4 Street •
• P.O.Box 428
DesM Ines,Iowa 50319 ''' Iowa Ctty, 52244
(515)725-6066 •
(515)72,5.6080 Fax • w'
- (319)338-9777 .
• Phone:
I. Eax: (319)339-7302
•
Lam re . Iliin an Iowa Criminal Histo ;Record Check on:
Last Name mandatory) ..iFirst Nalene(mandator•
y) Middle Nemo (r000mmandod)
Date of Birth (mardoto 'Gender(mandatory) i
,�SoClal•Secririty Number (neeommendadL4
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Waiver ��emaie (,. .5-,1� l� 9/-241
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Irf/brmaiiont Without a signed�'afver from the subject of the request,a complete criminal history record may not
be releasable,per Code of Iowa,Chapter 692,2. For p9mVletq criminal history.record information,as' allowed by Jaw,always
obtain a waiver signature from the sitb-lectrof the request., '
Waiver.Release;t hereby give pumic11011 for the`above regvalieg official to conduct en Iowa criminal Osiory ••rd ohcek with I ivislon of Criminal
Investigation(DCI). My criminal history,dt+taconeentah •. hat is me'rained by•tha DCI may be re)aaeod'Call. by law,
Waiver Signature: ,
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Z wa Criml>inaIllistory Record check Results - . . •'
yao only)
As of l� ._.., .4,j • r;t
, a seaxeixof the provided name and date of birth reveaad:•. IN) :=?_.I,,'
Na Iowa,Griznitll Histozy Record found with DCX '..- IE:.). * I�--,, .
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0 Iowa Criminal History record attaehed,'DCI I ��
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DCI-77(08/25/10) •`' ,
Received Time Jun. 22. 2018 11 :0444• No. 1023
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SMARTER I SIMPLER I CUSTOMER DRIVEN Iry rv.lawadatgav
Driver&IdeiWMk#tion Services
PO Box 9204 I Des Manes.IA 5-5341
Phone 515-744-9123 I Fax 515,239-1837
Certified Abstract of Driving Record
Inquiry Date: 6/22/2018 DL/ID#: 168AN5920 (IA) Customer#: 6611381
Name: Riner,Shane Class: C ID Status: VAL
Christopher
Address: 2876 CORAL CT APT Audit#: 2579258 DL Status: VAL
102
Issue Date: 02/26/2018 CDL Status: None
City/State: CORALVILLE, IA Expiration Date: 12/30/2023 CDL Cert Status: None
522412840
Endorsements: NONE CDL Med Status: fie
Mailing Address: 2876 CORAL CT APT Restrictions: NONE Restriction 7:-. N ie -oP4
102 Supplement i 1
Date of Birth: 12/30/1986 p...4 = ••••"*"
Mailing CORALVILLE, IA Sex: M C'7"c.
CO
City/State: 522412840 t�
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History Information n� =
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Convictions 7''
Citation Date Conviction Date ACD Explanation County JUR
09/03/2017 10/04/2017 B51 No Driver's License Johnson IA
Sanctions
Type Effective End ACD Explanation Occurrence JUR
JUR
Suspended 01/09/2018 02/22/2018 D53 Non-Payment of IA IA
Iowa Fine
Name: Riner, Shane Christopher DL/ID: 168AN5920
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:
N"°".. "44,t
I-" Tk 6/ 22/2018
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DOG Iowa Department of Transporation
Name: Riner, Shane Christopher DL/ID: 168AN5920
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