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HomeMy WebLinkAbout19-072P pis®�i CITY OF IOWA CITY IDENTIFICATION NO. le(—b-1 ;- (Office Use Only) �APPLICATION FOR TAXIC / "LED PEDICAB VEHICLE DRIVER (Police Department review must be made between 6 a.m. to 3 p.m., Monday— Friday) Univ SF? 25 PH 2: 51 410 East Washington Street rauur Iowa City, Iowa 52240-1826 (3 19) 356-5040 Last CI1 Y l;LthM �;'A CITY,1OV44 First " Middle (319) 356-5497 FAX 1. Name (REQUIRED) lith Prj-+" Hi✓i5 �� Yyl 2. Address (REQUIRED) oral ( W P5 IA'r ^ {( 3. Contact Information (REQUIRED) Email: lg4l+.,,,, �i �✓f;i{1 Ya ,(nom Cell Phone ��3 a2GSa (AII written communication sent via email) 4a. Driver's License expiration date (REQUIRED) 0/ -I;w— r�.5 b. Taxicab Business Name (REQUIRED) YP /l , bd C%9 10 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? Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested/ charged with any traffic offenses in the last five years? Type of offense Where When 91 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended lead Gui Other 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) /`I () (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 Page 2 APPLICATION FOR TAXICAB VEHICLE DRIVER DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTtFIF DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEFIRt;wk9 ;r You must apply for an individual Department of Criminal Investigation Repplf¢rm available upon request). LLJJ CCtP 20 P 1 2: 51 I hereb� certify that I have issued to me by the Iowa Department of Transpdr U6 Cal. (( Driver's license number �y NWys,0 issued on <95c-13-lq expiring on' I2 , , I 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 Applicant �j0, , "& 4ZZI�4 Date flfMlffflfflfM11Ni11iiiiR'lfffHlflfiftfiiilifW4f1111!ltki+Yl4fYflkiMffN1ff11tkfiiMiiiiliffifMtllf}tlffiffffllffffikf}flflrllf'flfiffif#1iNii STATE OF IOWA ) COUNTY OF JOHNSON ) before by R Y\ 1Ybv\ Abj^4L Sy'-�-\ this 2(d-1- 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). Expiration date. riv nse 1-Zt,-ZaZ -'9 7 9_L & Signaty"1of 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. Office Use Only Approved application DCI report State certified driving record Website update Date aerkrW1DRPAA1)GEAPPL9M1Bemended.DDC 04/2018 061Sep 25. 201.9 11:.U6cab DCI IOWA ffAK)379338 No. 1122 STAT Er OF IOWA 2014 SEP 25 PM Criminal $istoay Record CheckClTY CLEFT Request Fo1rm ', C I T Y, i 1 To: Iowa Division of Crtwieel iavestigarme Support Operanotra Bureau, l" Floor 21S Ii. 70 Street Dar Moines, lows 903ig (618) 7256066 (SM 725,6090 Ba: I an retrueetiar an Iowa fSimtnui Titelnry 2..,. A %...b ..-. DCI Account Number 99¢7-F (v.ypinoale) From YdIOW Cab of Iowa CltY P:O. Boz 428 Iowa Catn M. SM44 (319) Phone: FEW (319)3�1e. 02 P• . jJ021002 Ltiat Name (meaddary) 11W Name OMKWWW _.. Mi dlo Name repo For Date of Birth %04,w C„e,adelr .„ Social Seauft Number c7%� a f�' Male ©l emalec/ [� >9patl� InfOT/itnftnll' Witheat a signed waiver item the aabject of the regaaet, a domptete arimiaal history record may not be releaaahle, per Code of laws, Cbaptar 692.2. For Amet erimlaw Ws%ry record information, as allowed by hrw, always obtain gwativar stars from thp Sdblw of the rut. wahw'Rdff0e:IlwebygWe treamLolahAvdm Awe aguaadng am" to eaedact mrows aWaat ldnmyie obo*vAtbdn D"top orcdminel lnvoldptisn (Dc4 My Welled btnoq dao ednm&tngaa the i$ matrMood by/the l=may be relered as allowed bylaw, As of 9 D� �9 0 a marctl of tbo provided nam o and date of birth ❑ No Iowa Ctdminsl history Record found with DCI Iowa CrltninaI Hiritory R.eeord attached DCI # DCI imtietls "`� DCI -77 (08/25/10) Received Time Sep. 18, 2019 11:28AM No. 9828 00. 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Sep. 25. 2019 11:00AM DCI IOWA No. 1122 P. 3 DCI 00668551 PAGE 2 OF 2 An arrest without disposition is not an indication of guilt. This record maintained by the Iowa Division Of Criminal Investigation, Bureau Of FILED '--'^� ,„_ Identification is a public record but can only be released to non -law a� (1..,,j enforcement agencies by the DCI. p p This response can only include public criminal history data. Under IcwdolUE 26 PH 2: 51 most juvenile records are confidential. Confidential juvenile court recorda4 if any, cannot be included in this response. A signed release authorizatip101 i CLERK 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). Additionally, criminal history data concerning convictions for certain juvenile sex offenses can be found on the Iowa Sex Offender Registry: http://www, iowasexof fender. com/ . However, even though some information is available on this site, the actual records for juveniles 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). IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD I$ BASED ON INFORMATION FURNISH=, WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION 0 C10WADOT FLED SMARTER I SIMPLER 1 CUSTOMER DRIVEN www.i0wdddQ_tj� PH 2:51 Drb« & IderAft , . a R K PO Bolt 92U I Des fnanes la dps9lya ,101'1 � Phone 515-244-9124 Fax 515-miar7 Certified Abstract of Driving Record Inquiry Date: 9/18/2019 DL/ID #: Name: Henderson, Antron Class: Medical Examiner Last Name Maurice Medical Examiner License Number Address: 2031 WESTERN RD Audit #: Medical Examiner Jurisdiction IN Issue Date: City/State: IOWA CITY, IA Expiration Date: Medical Certificate Issued Date 522402333 Medical Certificate Expiration Date 203AD0440 (IA) Customer #: A ID Status: 3861959 05/23/2019 01/28/2025 Endorsements: Hazmat/Tank Mailing Address: 2031 WESTERN RD Restrictions: None Date of Birth: 01/28/1974 Mailing IOWA CITY, IA Sex: M City/State: 522402333 CDL Medical Examiner's Certificate DL Status: CDL Status: CDL Cert Status: CDL Med Status: Restriction Supplement: 4297837 EXP VAL VAL Non -Excepted Interstate Certified HazMat endorsement valid until 05/22/2024 Certificate Specifics Explanations Medical Examiner First Name Jayne Medical Examiner Middle Name L Medical Examiner Last Name Tar art Medical Examiner License Number 71002111A Medical Examiner National Registry Number 1962287446 Medical Examiner Jurisdiction IN Medical Examiner Phone 219 392-7424 Medical Examiner Type Advanced Practice Nurse Medical Certificate Issued Date 03/19/2019 Medical Certificate Expiration Date 03/19/2021 Date Added to CDLIS Driving Record 05/23/2019 History Information Convictions 01 0 2019 102/21/2019 S92 I Seed iGrundy IA Name: Henderson, Antron Maurice DL/iD: 203AD0440 Iffi lLED Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identification Servicig i Yo%PD4rtXAtZf TWnsportation, do hereby certify that I am the custodian of the records held by Driver & Identification Servicepjjglltt tIiLF"¢rue and accurate copy of an official record currently in the custody of said Office, and that I have been auiliPhAcl%Tti(e i#V"r 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 q¢QtrAM1O£ryr OF rQ{ryO f � 9J t\ fl Name: Henderson, Antron Maurice DL/ID: 203AD0440 9/18/2019 W Driver & Identification Services Iowa Department of Transporation