HomeMy WebLinkAbout19-002� r ,
CITY F IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 3S6-SO40
(319) 356-5497 FAX
Last
1. Name (REQUIRED)
2. Address (REQUIRED) _
IDENTIFICATION NO. Ct-t7(7a
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will resultm denial of the application
First
Middle
3. Contact Information (REQUIRED) Email: LOIL-4*1. )emenc 111 ���r �'1 c t m Cell Phone: 35Z Z S(o X 5 7
(All written communication sent via email)
4a. Drivers License expiration date (REQUIRED) 1) 17 -
b. Taxicab Business Name (REQUIRED) 1/G JI,,j Cc�)
J'
5. Prior experience in transportation of passengers:
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or els(Wherev +,
Tvce of offense Where en
w
y's1
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other �d
7. Have you been arrested / charged with any traffic offenses in the last five years?
Tvce of offense Where When
What happened to thech ? 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? (U/T
Tvce 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)
.n A
FOR
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 that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
19 5AN Z S nj issued on 1 -�expiring on /l-77-2oay . I understand that if
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 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant ��� Date / _ 3 �%!
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STATE OF IOWA
COUNTY OF JOHNSON
Subscribed and sworn to before me by
for
on this 11-� 0 G day of
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 welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code). _
Expiration date of nv icense /1' Z 7— 2,0o -Z y w
-'m
Sigre 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.
of City Clerk or
Office Use Only
Approved application
DCI report
State certified driving record
Website update
/ - 3 -/�
Date
Ger/rA%IDRN94D(iEAPPI-92010ame,geE.DDC 04/2018
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Received Time Dec.27. 2018 2:32PM No -6893
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PO Bat 5201 I Das IAolnes, IA S400L920r
Plane SIS -Z"1261 Fax SIS -2991887
Certified Abstract of Driving Record
Inquiry Date: 12/27/2018
Name: Barton, Jerome
Dennles JR
Address: 418 E 3RD ST
City/state: WEST LIBERTY, IA
527761437
Mailing Address: 418 E 3RD ST
Mallino
City/State:
Convictions
DL/ID #: 193AN2584 (IA) Customer #:
Class: C ID Status:
Audit #: 1932584
Issue Date: 07/01/2017
Expiration Date: 11/27/2024
Endorsements: NONE
Restrictions: NONE
Date of Birth: 11/27/1984
WEST LIBERTY, IA Sex: M
527761437
History Information
DL Status:
CDL Status:
CDL Cert Status:
CDL Med Status:
Restriction
Supplement:
0
Conviction Date
ACD
Explanation
6589311
1
None'Z
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IS15
ISDeed
VAL1
IL
None
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None
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None
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Citation Date
Conviction Date
ACD
Explanation
1county
102/12/2018
104/19/2018
IS15
ISDeed
_JUR
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IL
Name: Barton, Jerome Dennies JR DL/ID: 193AN2584
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:
12/27/2018
7
Driver & Identification Services
Iowa Department of Transporation