HomeMy WebLinkAbout19-062yql®r�11
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
IDENTIFICATION NO
q- c-oa
(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
1. Name (REQUIRED) Iv
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2. Address (REQUIRED) q Z() y U t f o 6 t, X 0 w c �.t r. L{� � 5 1 -IM
3. Contact Information (REQUIRED) Email: �a I 1 S ,j C) `�� wor.,1i 11 Phone:
(All written cc2ommunic6tion sent via email)
4a. Driver's License expiration date (REQUIRED) 7 (J Q Z u a--)-
b.
2b. Taxicab Business Name (REQUIRED) 5't 1 I e� �,� r U c, • f7
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? f S
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What happened to the charge? ( 'rcle ane)
onvict Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrest reed with any traffic offenses in the last five years? Xes
Type of offense Where When
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What happened to the charge? Circle one)
onvic d Dismissed Deferred Suspended Plead Guilty Other
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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)
04/2018
% 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 e issued to me by the Iowa De artment of Transportation a valid Driver's license number
�C�-� issued on Z- t expiring on I understand that if I
falsely answer any questions in this application, that this application may be denied. agr�n 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 provisioris-oi Title 5,GI7apter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by T_ , 4 S 1,3 . _]_ccc_this /--7--day of
Public iiQ $nd for the State 91 Iowa
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
' ' 08-ZZ--tR
Signature ofP61loe 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.
0412018
Office Use Only
o
Approved applicationo
DCI reporter
WJ
State certified driving record
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Website update
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0412018
08)A,g 20�2019,�1:39Pf Cab M 1UWA
ffAX)319 338�: °M' ' 7 I ' " . 5021002
STATE OF IOWA.
Criminal History Record Check,
' Request Por)m
DCI AccountNumbet: •„9967-F
y (If spollaably
Tot Iowa Division of Criminal 11tvestlgstion From: Yellow Cab orIowa City
Support Operations Bureau, 1" Floor P.O. Box 428
215 R, 7`4 Street
Dec Moinea' ZOwa 50319 Iowa City, IA. 52244
(515) 775-6066 '
(515) 7zS 6oao�Fax (319) 3389777
Pbone:
Fax: (319)'139-7307,
I am reauestine an Iowa Criminal History Record Check on:
Last Name (mandmory2
First Name mandatnryl
N idI le l AML raoommsndsd
..
Date of Birth mandato
Lend (mandatory)
'Social -Security Numbei twommonda.
Male. QFemale
Walver inforrkatlon: without a rimed waiver from tbesubject of the request, a complete trlmlnal history record Inlay no
be releasable, per Code of Iowa, Chapter 692.2• For g2oplot criminal history record information, as allowed by )aw, always
obtain a waiver signature froth the seb•ect of the reguest
Waiver.Release: ! hemby IlWa pormisslontor d.e above requestipg 00mW w conduct sa lows criminal himary record obsolt wlds tha Dlvlslm of Cr q?Jml
In�cinlprian (DCI). My crhningl history data oonoemin ma shat a inowl nWped by Me Da may.bn m)caerd as.aIIuwe3 by taw.
Waiver Signature.
Iowa CriminaMisto Rec rd ecJc a alts ;>', (✓i'•h Ci bsb'only)>
As of O � Lama search of the provided name and Hato of birth revea�d� A'TE OF IOWA/PP% `=
No Iowa Crim3n4istory Record found with DCI ci� `gjlo
RIMINAL INV
ei Iowa Criminal i4' 4s Record attached,.DCI # r—
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DCT initials_,_ oz
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DCI -77 (08125/10)
Received Time Aug -14. 2019 12:42PN1 No.4554
C401UVVADOT
SMARTER I SIMPLER I CUSTOMER DRIVENWVJhflCIOW9CjOt.gOV
DrivFt & Identification Services
PO Sex 92111 Des Mines. IA 613t02,92Di
PhCne 515244-91241FM 51E,239 -t&47
Certified Abstract of Driving Record
Inquiry Date:
8/14/2019
DL/ID #:
Name:
Jackson, Dallas
Class:
8858609
Joseph White
VAL
Address:
920 N GOVERNOR
Audit #:
07/30/2022
ST
None
Chauffeur 3
CDL Med Status:
Issue Date:
City/State:
IOWA CITY, IA
Expiration Date:
522455920
07/30/1989
Endorsements:
Mailing Address:
920 N GOVERNOR
Restrictions:
ST
Date of Birth:
Mailing
IOWA CITY, IA
Sex:
City/State:
522455920
Convictions
230AD2948 (IA)
Customer #:
5386301
D
ID Status:
EXP
8858609
DL Status:
VAL
02/19/2015
CDL Status:
None
07/30/2022
CDL Cert Status:
None
Chauffeur 3
CDL Med Status:
None
Corrective Lenses
Restriction
None
Supplement:
07/30/1989
M
History Information
Citation Date
Conviction Date
ACD
I Explanation iCounty
JUR
12/02/2015
01/05/2016
F34
Stopping on Johnson
Traveled Way
IA
Name: Jackson, Dallas Joseph White DL/ID: 230AD2948
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 1 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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Name: Jackson, Dallas Joseph White DL/ID: 230AD2948
8/14/2019
Driver & Identification Services
Iowa Department of Transporation
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