HomeMy WebLinkAbout21-027'r IDENTIFICATION NO. 2-1-02--7
(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)
CITY OF IOWA CITY
410 East Washington street Failure to complete the "reouired" information will resuh in denial of the application
Iowa City. Iowa 52240-1826
(3 19) 356-5040 Last First
(319) 3S6-5497 FAX Middle
1. Name (REQUIRED) "�L A r3 v� C \ y i y) r'
` CA -tom
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email: Cell Phone:
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) V2 G --iv- i1
5. Prior experience in transportation of passengers: A-
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? J
Type 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? 1V
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 chauffeur's license been suspended or revoked in the last five years? A,/ 0
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) /y(7
(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 h reby certify that I have issued to me by the Iowa Depart ent of Transpo� tion a alid D 'ver's license number
v� In �Vy0 issued on expiring on S%�I understand that if I
falsely answer any que ons in this application, that this app ica��ay 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 Tj e 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date_ - o9 - �>_l-Z j
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this
Notary Public in and for the State of Iowa
day of
*tfri****....+..**t**.*********+*:*****t*t**#***t**t***************+***t****t*«******#****�+.*+**t«t**�*t
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 license e�— /— Z o Z 6
Signat0 a of Police Chief or designee
Z//Z d-/Zo 2 /
' 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
Date
i#*t,M;*;##**t+ii#Ntt###*i-i;i##iiR;flet#ti##i*lttt*i#;#y;1t#;t*tt##i#+titHtlM1;;#;;fhti;;#;iMH:tftt*iii#;t1,*tt#;#Ytt+ltt*t;; #;i;#i*;tt##itt;ii;#*
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Clerk/rA%IDRNBADGEAPPL92018amended.DOC
04/2018
Pro,hp r. ). LULI IU: I)AM--imrk UUI IOWA 31a 3666487 04/02/2021 09:0•No. 0763a23P. 1/31003
Criminal History Record Check "xs�
Request Form
To: Iowa Division of CYiminal Investigation
Support Operations Bureau, V Floor
215 E. Ira Street
Des Moines, Iowa 50319
(515) 725.6066
(515)725-6080 Fax
1 641 fe0Ue5tillLr an Inura Cr(minni Uietnm R>...,.A t1h. .
DCI Aecounl Number; Li002 • F
p(nvnl--- ieabla�
From: Ctly of Iarva Cts
City Clerles office
410 I;, Washington Street
Iowa city, u $2240
Phone: 319-356-5041
Pat: 319-3564497
Last Name (mendartay)
First Name (mandamry)
Middle Nalne (mconsrawded)
As of w •aha-( a search of the provided name an f} s of liiitti 1 even;
T
Datee Of Birth Onandamry)
Gender (mandatory)
Social securityNnntber (r«ommend<d)
Q `-' (/ I C)
®Malo Female
� � `
Waiver Informp7fon: Without a signed waiver from file subject of the request -'a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For eomulere criminal hlslory record Information, as allowed by law, always
obtain a waiver signature from the subject of the request.
W(dVer ReieaSe:1 herebygive permission for thraboY612yuesling efrcial to conduct an loan crinlillal history record check .Sisk rhe Division ePCriminal
lnvesttganms (DCO. Any cinainai hLstory data conceming met tis mernsalned by the DC1 may be released as allowed by law.
wah)er signafare:
......d..`�"�1.1113t0ilrOfCr//igrr�
LbCr use only)
As of w •aha-( a search of the provided name an f} s of liiitti 1 even;
T
y
,
O
9
-o
m
h oy
No Iowa (. iminai History Record found with L tj �s(p4 C ;
s
CD
O
loa
® Iowa Criminal History Record attached DCT # _%fir •'•. art'' '
d
.;'V
0 /
DCI initials
DCI -77 (08/25/10)
Received Time Apr. 2. 2021 9:33AM No.0569
C41UWADOT
SMARTER I SIMPLER I CUSTOMER ORIVEM w`^""11awadAtgov
DOW s IsrttlBeal" Beeviga
PO Bar 9041 I Des Wines. IA 50306 WU
PWO 515-244-91241 Fax 515-299.18"
Certified Abstract of Driving Record
Inquiry Date: 4/25/2021 DL/ID #: 433ZZ6758(IA) Customer #: 1542644
Name: Truong, Trinh Cam Class: D ID Status: None
Address: 1404 PRAIRIE DU Audit #: 4282777 DL Status: VAL
CHIEN RD
Issue Date: 10/26/2019 CDL Status: None
City/State: IOWA CITY, IA Expiration Date: 06/01/2026 CDL Cert Status: None
522455614
Endorsements: Chauffeur 3 CDL Med Status: None
Mailing Address: 1404 PRAIRIE DU Restrictions: NONE Restriction None
CHIEN RD Supplement:
Date of Birth: 06/01/1970
Mailing IOWA CITY, IA Sex: F
City/State: 522455614
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
02/01/2017
02/02/2017
S92
Seed
Johnson
IA
11/10/2019
11/14/2019
M14
Fail to Obey Traffic
Sign/Signal
Johnson
IA
Name: Truong, Trinh Cam DL/ID: 433ZZ6758
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:
Name: Truong, Trinh Cam DL/ID: 433ZZ6758
4/25/2021
C.�
Driver & Identification Services
Iowa Department of Transporation
dlly-tb—