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HomeMy WebLinkAbout19-0841 t t CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ IDENTIFICATION NO. )10' ©�;- (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 2. Address (REQUIRED) / oS 3. Contact Information (REQUIRED) Email: A communig9tion sent 4a. Driver's License expiration date (REQUIRED) ?J 3 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pasengers: Middle ��res Cell Phones-V�7— -/3 61 71 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead GuiltyOther 7. Have you been arrested / charged with any traffic offenses in the last five years? 1W Type of offense W here When What happened to the charge? (Circle one) 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? iC.l(/ 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) / V (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 o me by the Iowa e a ent of Transportatio a alid Driver's license number �l3y lc 20 7 /fexpiring on o� I understand that if I false) answe V 7 �� �� issued on y / y questions in this application, that this app is tion may be denied. I gre 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 lication, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provi 'on of Title hapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applican Date � STATE OF IOWA ) COUNTY OF JOHNSON ) Sunbs1cribed and sworn to before me by lzolat-' l 7 TiLN t i :M- ` on this 5 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 of Dd S li/nom 0 Z -6%i-Ze,Z--;;' ls� 7 1 SignatyFe of 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. City Approved application Office Use Only DCI report State certified driving record Website update Date Caen✓ AXIDRi DGEAPPL92OlMmndecmC 04/2018 Nov. 7.2019 2:08PM DCI IOWA No.7634 P, 5 1110412019 12:52 Yellow Cab !AN)3193382708 P.0021002 STATE 1 S �w.tLl Ute+ Request Form la (if vploble) Mtn .r p" CMR10tedfong to -,y Send resdts to: Iowa Division of Cr®inxl Inves4atim Support Werndone Borean� I�Ftoor 215 E. 7's Street ' 1)ea llloine�, Iowa 90319 , (SM 729 6066 (515) 725-6080 Fax Name . Xe1l6wXA of Iowa Cllr Address P.0,Bex428 Iowa Ckv.Iows 522244 Pboae (3191338-9777 Fax 319 359-4142 ;��a�/�'�t, �; I �Male )❑Female �lioiio :• ;; I'opriinaGtl� ' As of a sedroh oflhe provided roma and date of birth revicelodi ?` ;o . O s u� bio Iavnl 1Tlatory�%cord fonrxd with D 4 :c,��� Iowa.Criminni Elistoi?'y.Record attached, ACI # .'r zz$ ntil DCI iuitla]s,` °q'uu+uemenlalloot` D=7 (apdoWd 06.264018) y page 1 of Roraivad Tim• Nnv d 7014 11 d4P.M Nn 71A7 hy'•, S'MARTERISIMPLk:RC410WARPI WUVWi01lYF8i�f3 igiYYJ Dr41 e13atr ft N%onS5-M PO tUx9'+.A4I Dasfr�Rs.IA 61g06.92bt .c1101JC 5IG244-DIZIIF=415.23961= Certified Abstract of Driving Record Inquiry Date: 11/1/2019 DL/ID #: Customer #: 3313836 Class: Name: Fann, Robertlames JR Audit#: Address: 301 GREEN ACRES DR Issue Date: 02/09/2027 CDL Permit Restrictions: Expiration Date: City/State: SOLON, IA 523339711 Endorsements: Mailing -Address: PO BOX 95 _ Restrictions: None CDL Status: Restriction Mailing City/State: SOLON, IA 523330095 Supplement: Data of Birth: 2/9/1956 Nan -Excepted Interstate Sex: M Certified CDL Medical Examinees Certificate 713VY6707 (]A) CDL Permit Class: None A CDL Permit Issue Date: None 3581879 CDL Permit Expiration Date: None 02/01/2019 CDL Permit Endorsements: None 02/09/2027 CDL Permit Restrictions: None Tank ID Status: None Corrective Lenses DL Status: VAL None CDL Status: VAL Date Added W CDLIS Driving Record CDL Permit Status: ELG _ CDL Cert Status: Nan -Excepted Interstate CDL Med Status: Certified Certificate Specific. Explanations Metlical Examiner First Name— Ran Medical Examiner Mltltlle Name S Medical Examiner Last •.e SWrud_. Medical Examiner License Number 497 --- _ Examiner National Regltrlr Number Medical s Medical X4886891869 Medical ExaminerJurlsdictlan T SD Medical Examiner phone 701) 237-5150 Medical Examiner Type- R .._.C1romctor - Medical CertiFlca[e Resmc[lon 1 I — _ _ wearing corrective lenses Medical CemOcate Issuetl Date 11 Medical Cemgcate Expimticn Date _ _ _ _ _ 13/00/2019 Date Added W CDLIS Driving Record 02/01/2019 CDL Downgrades EHecfive End Issuing JUR 04/21/2017 History Information Convictions Citation Date Conviction Date ACD Explanation Lahan9ing lanes) —!M42 Imne(c JUR —I �IA 7County hohnson 01/08/2017 04/18/2017 proper �IA Pohnson 03/17/2017 106/08/2017 TM42 Improper Lane (changing lanes) Accidents -Accident involvement Indicated does NOT mean the individual was at fault or given a citation. IA _ 1647531 IA Name: Fann, Robert lames JR DL/ID: 713W6707 (IA) Pursuant W Iowa Code §321.10, I, Darcy, Doty, Driver & Identilication Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by Driver &-ldendOcaoon Services, that this Is a true and accurate copy of an official record currently In the custody of said ofOce, and that I have been authorized by the Director of the Iowa Department of Transportation W so Certify. In witness whereof, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: I1//uzJo19 + Driver & Identification Services ^l o° Iowa Department of Transportation Name: Fann, Robert lames IR DL/ID: 713YY6707 (IA)