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HomeMy WebLinkAbout19-064w f � r CITY OF IOWA CITY 410 East Washing(on Street Iowa City, Iowa 52 240-1 826 (319) 3S6-5040 (319)3S6-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) _ IDENTIFICATION NO. V A - ©lQu (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 3. Contact Information (REQUIRED) Email: IS �1N Kh16 S -P} latl I CP'(% Phone: 3I c -S-(�00 ,ag3 Z (All written communicafWn sent via email) 4a. Driver's License expiration date (REQUIRED) / / / r Z / Z--1 b. Taxicab Business Name (REQUIRED) (P //^A/ 696 a4J/a c- 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? ^I S Tvce of offense Where When 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? Tvoe of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred SuspendedPlead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? %C G 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) (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 have issued to me by the Iowa Department of Transportation a valid Driver's license number tel/// fy I7 S 3 issued on G5 expiring on c I understand that K I falsely answer any questions in this application, that this application Ly be denied. agre 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, H authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Tlitle 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant e�d®rt Dated Z flff#'###ff4f ##f#f#fff+f f f f fff f f f1f f 1f111f11f1ff1ff 1fHH1}fe*#**#4#i#*#M:#####*t##i##f'H##t##!*#f#**yy*1f#}11f 11f11ffflf###yr##fffffifffffflff#1f# STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by J F �e}ri�lL (-�2orAg Mc dde _ on this Z� day of AY-FLAT No. 765030 Notary Public i r the of Iowa W ASHLEY A J o Commission 111I.Gamm ..q GA wip" iow� July 14,2D20' 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). r�d Expiratioa f ver' rise S�ture of Police Chief or designee !I - Zz—zazLl" 8z�-�i 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. Office Use Only Approved application DCI report State certified driving record Website update Ge*ffAXIORNBADGEAPPL92018an ded.Doc 04/2018 oslAdg. 23. 2019);12:41PN Cob DCI a IOWA J • q:A)Wj9 338;N o. 6 12 3 P. 4/521002 STATE OF IOWA CIr'iiminal History Record Check Request Form Q-A- eeouut-Number. _99{x7 F • (Ihonllubld To: Iowa Division of Crl)nlne, lnvestjgaLlon Support Operations Bureau, l" Ploor 215 E. 7" Street Des HDIVevr Iowa 50319 I' (515)725-6066 (515) 725-6080. Pax 1M A% tp 61.-) F -n I am requesting an Iowa Criminal Iiistory l•2ecord Cherle nn •' From: Yellow.Cah of Iowa C1 P.O. Boz 428 Iowa City, IA 52244 (319)938-9777 Phouet )Farr (319) 339-7302 Last Name (mandatory) F�iJr9t NaMe mdato MICI$le N(fmo Naamrnoi dad) l�A Q�� l C�� : Giji Do I2 eC- Date of Birth (mandatory) Gender mandarn Social•seeu2 i Number rwomIDaaded Z.2 O. -Wager jil. - Wale ❑pemale = C' % -�— l9 �— �o Information: Without a signed;ryaiver from the subject of the request, s homplgte grtminal hlsrory record rpsy not be releasable, per Code otrows, Chapter 602.2. rror complete criminal history.reeord informgtl0% as eItowed by law, ;always obtain a waiver at nature from the sub eot 'f the request. Waiver Release: I horcby glva pannisrim fot ttCAbeve requea8r16 GM64 to wndutt an Iowa trim)nd hlemry rawrd ehook path rha Division of Urninel 1nvab1ig5tian(DC1), Any criminal hiamry deraawncaming me that Is malntalhad bycircDCI mqy bd r mold w-alloweq by Inw. T•Y!aivor Slgnaiura:% A^�+ ��` �-�— '• - As of (D I �3 �q a'search: of the provided name and date of birth No Iowa Criminal Hista"y Record found with DCI Iowa Criminal Kistoxy 1 ecosdppatttaJaohad,•DCI ACI iidtielp(`�.. DCT -77 (08125/10) Received Time Aug, 19, 2019 10;38AM No. 5214 W v c) X. cp . - z W Aug. 23. 2019 12:41PM DCI IOWA No. b123 V. V/ DISCLAIMER This response can only include public criminal history data. Under Iowa law, most Juvenile records are confidential. Confidential 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 confidential juvenile records, if any, an application must be filed pursuant to Iowa Code section 232.147(18). AtlHifionally,—criminal hisrda a coming conic ons for�ain juvenile sex offenses can be found on the Iowa Sex Offender Registry. http.11www.iowasexoffender.com/. However, even though some information is available on this site, the actual records forJuveniles 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). C10 DO vvww.iowado gav SMARTER I SIMPLER 1 CUSTOMER DRIVEN Driver $ Idegiftmro $mites RO Box 9206 I Des Moirom IA 50309-M Phone: 515-244-91241 Fax: 515.2 1&47 Certified Abstract of Driving Record Inquiry Date: 8/19/2019 DL/ID #: 701YY1753 (IA) Customer #: 2857327 Name: Madden, Patrick Class: D ID Status: None George Address: 3009 12TH AVE SW Audit #: 1549858 DL Status: VAL APT 102 Issue Date: 01/13/2017 City/State: CEDAR RAPIDS, IA Expiration Date: 11/22/2024 524041460 Endorsements: Chauffeur 3 Mailing Address: 3009 12TH AVE SW Restrictions: Corrective Lenses APT 113 Date of Birth: 11/22/1950 Mailing CEDAR RAPIDS, IA Sex: M City/State: 524041459 History Information Convictions CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: Citation Date Conviction Date ACD Ex lanation lCounty JUR 04/04/2017 04 06/2017 S92 Seed Johnson I IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 11/03/2015 887389 IA 05/02/2017 980954 IA 05/07/2017 987758 IA 05/09/2018 1046460 IA Name: Madden, Patrick George DL/ID: 701YY1753 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: 8/19/2019 Name: Madden, Patrick George DL/ID: 701YY1753 Driver & Identification Services Iowa Department of Transporation