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Home My WebLink About19-082� r CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 3S6-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) 1 IDENTIFICATION NO. 2 -- (Office (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 resuk in denial of the application Last First Middle -eatl ii4 ru 1 na e '�ti CQ.dc.,e Ib ilt4o( 3. Contact Information (REQUIRED) Email: r4 , M`g0•I , `dM Cell Phone:�� (Allittenv� communication sent via email) 4a. Driver's License expiration date (REQUIRED) `\K V b. Taxicab Business Name (REQUIRED) Ni lIlav/ pos%"y 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? \46 Tvce of offense Where When r - c, 15 P� bvia "Dii Titttyr(i pQ.d�e' L' ncd�r t a.Ot�t What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended lead Guil Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? tj ( 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) PAGE 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�JidJa.�a� I h b certify that f�ave issued to me by the Iowa Dep ment of Transpo i I' Driver's license number �� issued on S 1 expiring on I understand that if I falsely answer any questions in this application, that this applicat on may be denied. I agree t at 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, �yCe�hapter 2, of the City Code. (Needs to �be� signed in front of a Notary Public) Signature of Applicant l Q `t&xk Datet -}" }� HHIIHH;Hflff4HH11Nf}HNHHH}H11ff1fef11HHf;;f fHf}i;; 11HHY}f; 11Hlf f;1H#11;iyHHH;HHf}tRHfHHH1ff1;1ffffflf;HlH;Hf f 1f} STATE OF IOWA ) COUNTY OF JOHNSON I 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 Driver's Signature i lZ--/0 - 7a7: C7 or assignee /`l 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. Signature of City Clerk or designee N1111f1yf1fHN111lflflfllff tf1;-11f141111HffM1flifNlHHN1Nf}N11N1NHlNNN1fi-11NHf1f1fN4H;NN1tMNf111Nff}f}11t1fflffyfflfyflff Approved application DCI report State certified driving record Website update Office Use Only Cie AXIDRIV&ADGEAWI_92o16aa naj DOC 04/2018 Fro Oe t; 22. 2019wtl8: 42AMCloek DC[ IOWA a,® a66aa®7 ,0/16,20,® 08:gdNo. 5153,. P, �6/6002 STATE OF IOWA fiyOa �'^ i I 1, a: Request Form' To: Iowa Division of Criminal Investigation Support Operations Bureau, I" Floor 215R. 71h Street Des Mehies, Lown 50319 (515)725-6066 (515) 725-6000 Fos I fl1II r0nitegtink an InWa [`ri\n;nat liiahnnr Aw.nra f'I.e�L ..... DCIAccountNumber; (ifappliceblc) From; Clty of Iowa Clty Clty Clerlo! OtTice 410 E. Washington Street Iowa City, IA 52240 Phone: 319-356-5041 . Fax: 319-356-5497 Last Name (mandatory) First Name (menawory) middle Name (reccinmendelo Date of Birth (mandelo ) Gender (mandatory) Social SecuritF Number (recommended) 11''1 0 U5 gbtale IJFemale qJ 0-1 - 9 1- - Waiver.TW, orrriadort: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For corn lete criminal history record information, as Allowed by law, always obtain a waiver signature from the subject of the request, Waiver ReleaSe:I hcmbygive pemdssion for the ebovc requesting official to conduct en Iowa alminal history record cbcck Will ncoDivltion of crlmhis) InvesOgation (nCU, kny criminal hislory data concerning me -Vint is by Ole DCl may be nilensed m allowed by law, oaintained // Waiver Signature: 7"n�1 wem rr, , iLowa urlminai 111story IKeCord Check Results n)1a -• "'1 '', Np •.fIufgonlY) Asof �b'iJ.'� = �0I (W s search of the provided name and date of bifill rei ��d r, y ; a _ w ^�• ry 71j'a: > a z ---ado Iowa Criminal history Record found with DCI its ® Iowa Criminal History Record attached, DCI # 4" o C1,�0� f� r cY LL DCI initials 7 n DCI -77 (06/25/10) Received Time Oct, 16. 2019 8139AM No, 4306 C410WADOT www.Iowadot.gav SMARTER I SIMPLER I CUSTOMER DRIVEN Driver& Identification Services PO Box 92.041 Des Moises, iA:4546-SM11 Poon: 515.244.91241 Fox: 515.239.11337 Inquiry Date: 10/23/2019 Customer #: 5833406 Name: Beall, Gary Lee Address: 310 5th Ave SE Apt 703 City/State: Mailing Address: Mailing City/State: Date of Birth: Sex: Certified Abstract of Driving Record DL/ID #: 776AK1389 (IA) Class: C Audit #: 3838838 Issue Date: 05/14/2019 Expiration Date: 12/10/2024 Cedar Rapids, IA 524011817 Endorsements: NONE 310 5th Ave SE Apt 703 Restrictions: Corrective Lenses Restriction None Cedar Rapids, IA 524011817 Supplement: 12/10/1965 M History Information CLEAR DRIVING RECORD Name: Beall, Gary Lee DL/ID: 776AK1389 (IA) CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: VAL DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None 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: Beall, Gary Lee DL/ID: 776AK1389 (IA) 10/23/2019 A212 110�-u Driver & Identification Services Iowa Department of Transportation