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HomeMy WebLinkAbout22-008 IDENTIFICATION NO. 2,--OD� • ` l (Office Use Only) pan?lib hie On 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 "required"information will result in denial of the application Iowa City, Iowa S2240-1826 (319) 356-5040 Last First Middle (3I9) 356-5497 FAX l 1. Name (REQUIRED) e�d f+ Ck5 �l 0 cCd -/-f- Aivl 2. Address (REQUIRED) Li) 0 3. Contact Information (REQUIRED) Email: '"I e/'1 �G `T+''I�`t' I, .d m Cell Phone: —'17f `6/LT (All written communication sent via email) 4a. Driver's License expiration date(REQUIRED) OLO2/2 'DLI ,s°. �! b. Taxicab Business Name (REQUIRED) Pe Pao we r^ 5. Prior experience in transportation of passengers: fl U'r)� 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? (VO 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? fro 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? "h 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) (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 to me by the Iowa Department of Transportati n a valid Driver's license number Life (-C. I?. I I issued on oS/vy/)eir expiring on o'/ -2/20.2,-% . 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 /� Date /2 //2 ) 2 KARL Qt: 'iiie � Dwtnrt o-_Muftiar+�3"T.'. ******************************* **************************************************************** ,! or* � ` ;,ir ********* eM/Vl ..J1' _ t. STATE OF IOWA ) (. COUNTY OF JOHNSON ) Subscribed and sworn to before me by S(fr}f F _ 4-(12,4•1, c,t 0v1 on this a1J') day of j ad • \ ,tA--2, Notary Public in and for the State of Iowa 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 02/e° 2 //gt/4 - /2t/go 2- z" Si ature 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. c.. i -2-1 / .2--CX --- ---_. Sign ure of City Clerk or, signee D Date Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAX DRI VBADGEAPPL92018arrended.DOC 04/2018 ° y :3 , _ 1 _ �, ' s, gut:, y Jr r � i OadO ,SMARTER i S6 '4PLEIc I CUSTOMER DRIVER Driver&Cderailication Services PO ec,x 24(Des Moines,tA51136-5204 Prone;515-74-1-91224`I Fax''5I 2 +-1B3 Certified Abstract of Driving Record Inquiry Date: 6/16/2022 DL/ID#: 410LL1211 (IA) Customer#: 3874164 Name: Hendrickson, Scott Class: C ID Status: None Allen Address: 2420 N RIDGE DR Audit#: 2788581 DL Status: VAL Issue Date: 05/08/2018 CDL Status: None City/State: CORALVILLE, IA Expiration Date: 04/12/2024 CDL Cert Status: None 522411387 Endorsements: NONE CDL Med Status: None Mailing Address: 2420 N RIDGE DR Restrictions: NONE Restriction None Supplement: Date of Birth: 04/12/1977 Mailing CORALVILLE, IA Sex: M City/State: 522411387 History Information CLEAR DRIVING RECORD Name: Hendrickson, Scott Allen DL/ID: 410LL1211 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: . rir tar Fht 6/16/2022 I IS (71{., fx'e Driver&Identification Services f r'.t DDt `, Iowa Department of Transporation Name: Hendrickson, Scott Allen DL/ID: 410LL1211 voliti,, STATE IF 1•WA igtzry l'ec*rd Ch ©k 4" ,:v; !A l'i'eq ste Form ?;.,,,..,-- 7-5i-7 ; sizi.=:**,, qv ow., I,CIT Account Number: (if applicable) Mail or Fax completed forms to: Send results to: Iowa Division of Criminal Investigation Name bill 3i\\ICt er I e-eciod Support Operations Operations Tureau,]St Floor 215 E.7th Street Address jai 0, 5 4-v1 Ai eS Des - Des Moines,Iowa 50319 (515)725-6066 0 0 el(kr f_x p I-61 3, ITA 5 0,4163 (515)725-6000 Fax Phone 3 1 - Fax I am re.uestin• an Iowa Criminal Histo Record Check on: Last Name (mandatory) First Na!fie(mandatory) Middle Na dm e(recommended) C Oi I 111..te of Birth (mandatory) Gender(mandatory) ' SOCILit Security Number(recommended) . -I a- )917 laMalle EllFemale • L\ a- 04- sNU) Release Authorization: Without a signed release from the subject of the regurat,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 692.2.For complete criminal history record information,as allowed by law, always obtain a signed release from the subject of the request. ***This form(DCI-77)is the only approved release authorization form for this purpose.*** Release Authorization: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation(DCI). My criminal history data concerning me that is maintained by the DCI may be released as allowed by law. I understand this can include information concerning completed deferred judgments and arrests without dispositions. Release Authorization Signature: ..ommummuu., Iowa Crimin:d History Record ChecloRestirtg S cte 4 (DCI use only) . 9.. . CI As of of 6/3(20 2-7- , a search of the provided nameiAnicikli,i619Kbirth reveal:dd.-1 cn io C C,,,,, 6 ,.,,,t --:- m --i > ,'fh, 1 '''fr 'i,"::ii . L ' 7 0 C m al 0 13 No Iowa Criminal History Record found with l s iet % _6,/ . (ts ..` -.). . 2- 3 r- c= 0 Iowa Criminal History Record attached, DCI# ,,1/4-zon sectk,0%"\',„o \ F.-) > Z P‘,/ ----• 1/1"';nittntItItt,OA < M -0 DCI initials C /0(---- • cn , '..44.4 --.1 cn -4, .• DCI-77(updated 06-26-2018) ,.. .., Page 1 of 2 )