HomeMy WebLinkAbout19-096IDENTIFICATION NO. Ia-AD% D
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday– Friday)
410 East Washington Street Failure to complete the "required" information will result in denial of the application
Iowa City, Iowa 52240-1826
(319)356-5040 Last
(319) 356-5497 FAX
1. Name (REQUIRED) 1
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email:
4a. Driver's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. P ' r experience in transportation of ssengers:
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First Middle
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6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?_
Type of offense Where When
.a
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? /�) 0_
Tvce of offense Where When
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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? /V C-)
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)
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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 her y t t ve issued to me by the Iowa aMfionay
,gf portation a valid D' s license number
�P issued on i�zp�'n dS understand that if I
falsely answ ques ions in this application, that this appli be denied. I a ree 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
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 4;1C pn c Ij L� r�t4 on this 9 day of
S. MAYER
_ _.10 1, otary Puble in and for the Sta of Iowa
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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 lic e cil o �" Zca2 7
Signaty ey olice 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.
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Office Use Only
Approved application
DCI report
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State certified driving record
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Website update
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Dec. 6. 2019 12:28PM
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DCI IOWA No. 0971 P. 1/3
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STATE OF IOWA
Criminal history Record Check
Request Form
Meil Ln Pax completed forms to:
Iowa Dlvlelon of Crbninal Invpti8atlon
Support Operatious Bureau, I" Floor
215 E. 7b Street
Des Moines, Iowa 50319
(515) 725-6066
(515)725-6080 Fax
I am req=tina an Iowa C aminal History Record Check on:
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DCI Account Number: 9967-P
(if ryytiotDh) �` .�
Send results to: 7 n ?�
Name Yelldw,Cob of Iowa City
Address P.O. Box 428
Iowa City, Iowa 52244 '
Phone (319)338-9777
F" 319-359.414.1
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As of oZ- 6 �� a aearch of the provided name and #.a •• •, �
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E OF IOWA/DPS
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No Iowa Criminal History Record found with DQ ' t v 022019
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\� •, -As. plVti R -CRIMINAL INVEST
❑ Iowa Criminal History Rword attached, DCI # fu K)
DCI initials_ .•,, IIIIIUUf
DCI -77 (updated 06-26-20 18)
Page I oft
Received Time Dec. 2. 2019 1:37PM No. 0162
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SMARTER 1 SIMPLER I CUSTOMER DRIVEN www.iowadotgoy
Driver & idual6o~ 6mioN
PO Box 92041 Des Moines IA 503D6 -920I
Phone 515-244-9124 1 Fax 515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 12/2/2019 DL/ID #: 363AR9986 (IA) Customer #: 6871721
Name: Brown, Richard Paul Class: C ID Status: VAL
Address: 429 Southgate Ave Audit #: 4332166 DL Status: VAL
Issue Date: 11/15/2019 CDL Status: None
City/State: Iowa City, IA Expiration Date: 01/05/2027 CDL Cert Status: None
522404401
Endorsements: NONE CDL Med Status: None
Mailing Address: 429 Southgate Ave Restrictions: NONE Restriction None
Supplement:
Date of Birth: 01/05/1987
Mailing Iowa City, IA Sex: M
City/State: 522404401
History Information
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CLEAR DRIVING RECORD C:)
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Name: Brown, Richard Paul DL/ID: 363AR9986 p��¢^ w i � l
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Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa DepartrrveKt of Transportation,
do hereby certify that I am the custodian of the records held by Driver & Identification Services, that this is a trud-Snd 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: Brown, Richard Paul DL/ID: 363AR9986
12/2/2019
Driver & Identification Services
Iowa Department of Transporation