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PEDICAB Non Motorized Horse Drawn Driver APP 2015 IDENTIFICATION NO. ___________________ (Office Use Only) clerk/Non Motorized Pedicab/Horse Drawn Drive App.doc 03/2015 APPLICATION FOR NON MOTORIZED PEDICAB DRIVER/HORSEDRAWN DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday – Friday.) First Middle Last 1. Name (Required) 2. Address (Required) 3. Contact Information (Required) Email: ______ _____Cell Phone: 4a.. Driver’s License expiration date (Required): b. Pedicab/Horsedrawn Business Name (Required): 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? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Deferred Suspended Plead Guilty Other_______________________ 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Deferred Suspended Plead Guilty Other_______________________ 8. Has your driver’s license or chauffeur’s license been suspended or revoked in the last five years? Type of offense Where When 9. Have you ever applied to be an Iowa City pedicab/horsedrawn driver using a different name? If yes, please provide the name(s) 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) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) clerk/Pedicab Non Motorized Horsedrawn Driver APP 2015.doc I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver’s license number _____________________________________ issued on ______________ expiring on ___________. 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 a license is granted, to comply at all times with all of the pro- visions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant_________________________________ Date_______________ ************************************************************************************************************************************************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by ____________________________________. On this ___________ day of _____________________. ________________________________________ 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 deter- mined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code). Signature of Police Chief or designee Date AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A PEDICAB/HORSEDRAWN VEHICLE IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. THE EFFECTIVE DATE WILL MATCH THE DRIVER’S LICENSE EXPIRATION IF LESS THAN A YEAR. Signature of City Clerk or designee Date ************************************************************************************************************************************************ Office Use Only Approved application DCI report State certified driving record Website update