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HomeMy WebLinkAbout19-056t CITY F IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. I G --O eJ LO (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 result in denial of the application Last First Middle U .l ZSrti LYi 2. Address (REQUIRED) ' ©'? CJ/,? i be rY1 S S6rrrr y 3. Contact Information (REQUIRED) Email: �� � W, Y r j(e �✓ Ca L,, � c c Ceu Phone:./� 3J�J' Si, y8' (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) /— -4 d 4 U b. Taxicab Business Name (REQUIRED) V ', I (o W C g b i 5. Prior experience in transportation of passengers:/Hifi p 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When N O Q LD :LY M7 Ffl What happened to the charge? (Circle one) Convicted Dismissed r Deferred Suspended Plead Guilty OthTr' 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When 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? a 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) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/20118 Page 2 APPLICATION FOR TAXICAB VEHICLE DRIVER 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 issued to me by the Iowa Depar&nt gf Transportation a valid Driver's license number !� rr issued on,4 -p*.J c ekpiring on,/ -,;P4.01 understand that if I 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 Applican Date — � o { `� 4f 1NRiiYN4NNIfMillifNYyrNYNYNNYflil�iifl!'FinH1fNMN1ff f 1NNNfffffNf11ff111f1f f!f 11fNfflffffflfY141fNNf f 11fNHNfff f f lff FINN STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by C-7 re c on this r 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 or welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). N O Expiration date of Driv i 2 ZC/ Z/J Si ure of Police Chief or designee Datil r,, o T rt— o� � 0 AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IiVIOWA 0TY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. `n or Office Use Only Approved application DCI report State certified driving record Website update Date C4M AX1DRNBADGEAPR92018emen .DOC 04/2018 07/nug_ -11-1 Cab A,I IUWA + 1rSTATE OF • C4mlrial History Record Request 1 11 i To: Iowa Division of Crlmliial.lnvesl nation Support Operations Bureau, I"e.+)oor 215 E. lei street Des Moibas, Iowa 50319 (51.5) 725-6066 (515)725.6080 Fax Sc k v (T =- -5A . of Pt (' Y ffAM193382No.2842 r•• 1021002 DCI Acconiit M =bor: _9967-F (ircvpllutda) From; Yellow Cab of Iowa Ci P.O, Box 428 Tows City, IA ;:5 24 o,t r (31.9) 338-977 h Phone: Paz: (319) 339-7302 Irakvi,ale ❑k'8=16 Watv6TLltfOTmafian: Without a signed waiver from the subject of the request, it complete criminal history record spay not be releasable, per Code of Iowa, Chapter 692.2. For Complete criminal history record in,orniglion, as allowed by {a W, always obtain a waiver sikynature from the subject.of the reoueAt Waiver 12eka.4et k hereby aloe patmlllloa 10r tho Wove MQUUdns aMfohl to oonduct m lawn arlinlnal.blatory roeard oheok with the Divhlan ofCriminal Inveatlaittoa (DCD, Any odminal hlamry den dMeerrUg me rhst is maintained by the DCI may be teltasced ereuoweq by)1W. Waiver As of ` a search, of the provided name o Iowa Criminal Histoi!xy Record found with I a'. ❑ Iowa Criminal Mstory Record attached,•DCI #_ ]XI 1.- itiais DCI -77 (08/25/10) • Received Time Jul, 29. 2019 9:48AM No, 1915 . A e4'IGJ_1R1U9'..•.. �[y ' COCl we 0. late of birrh���eaie`d; r V•l a eSU_' O oa h�SYOCy o O ery x J U U. O '�,�„t�•r�ritittatiLOo�o``� eF --nmmmmtota p ug. L. /V IJ Y:)DNm it'i 1VWh No. idQ Y. 1 DISCLAIMER This response can only include public criminal history data. Under Iowa law, most juvenile records are confidential. Confidentlai juvenile court records, if any, cannot be included in this response. A signed release authorization is not sufficient to obtain this information from the Division of Criminal Investigation. In order to request the release of contidentiai juvenile records, /f any, an application must be riled pursuant to Iowa Code section 232.147(98). Additionally, criminal history data concerning convictions for certain juvenile sex offenses can be found on the Iowa Sex Offender Registry. http:l/www.iowasexoffender.com/. However, even though some Information Is available on this site, the actual records for juvenfies may still be confidential and any confidential juvenile records cannot be provided with this record. In order to request the release of confidential juvenile records, If any, an application must be filed pursuant to Iowa Code section 232.147(18). 0 1 n � ;7 Cr OW- ADu- �81.'SMANTO I IMPLER I CI�T6 MIE9 �Ik�E� �++�+r+w� Va a�io�: tr _ �©Iidp�P 8 if�tidN $�paY(6a5 pr,�:sBDcseecl�ne^� rA PtItDgB 511154ll24 I Fox sy 1W Certified Abstract of Driving Record Inquiry Date: 6/25/2019 DL/ID #: 151vv7069 (IA) CDL Permit Class: None Customer #: 1246896 Class: D CDL Permit Issue None Date: Name: Schultz, Gary Lynn SR Audit #: 3461531 CDL Permit None Expiration Date: Address: 909 Chatham St Issue Date: 12/12/2018 CDL Permit None Endorsements: Expiration Date: 12/26/2020 CDL Permit None Restrictions: City/State: Williamsburg, IA 52361 Endorsements: Chauffeur 1 ID Status: None Mailing PO BOX 923 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing WILLIAMSBURG, IA Supplement: CDL Permit Status: ELG City/State: 523610923 Date of Birth: 12/26/1945 CDL Cert Status: Excepted Interstate Sex: M CDL Med Status: None History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date JUR Case Number 05/31/2018 IA 1069607 Name: Schultz, Gary Lynn SR DL/ID: 151w7069 (IA) Pursuant to Iowa Code §321.10, I, Darcy Doty, 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: Name: Schultz, Gary Lynn SR DL/ID: 151vv7069 (IA) N O 6/25/2019 O `� I r Driver & Identification Services Gr -� IT Iowa Department of Transportatlon—M S Q O�