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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
IE)E:NTI)m C A°T1ION IN(.
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APdPLIck'INION II::OR TAXICAB U MOT"ORMED PE:IIDICAB VEI IIICI...IC!: IIDRIVEIR
(Ifaollice Department irevilow must Ibe made between 8 a, irnn. to 3 p.m., Irllp,onday. ..... Firlday)
�e,a //l� l > > r✓;I,f�f/✓ /f; (/t�° `Jr W; // "X'P, I,III'omiayrlrol
First
1. Name ,ll;l,H.,y1dll"I ";k 1,K 1.
2. Address(RMtl.RflRED) Hsu^ H)ottatvlv,w .,. ,,
3. Contact Information I ,1 QU 1 R1 kl Email: �—Cell Phone VI L 1 9
All w ittenmcahoneemil
4a. Chauffeur's License expiration date
b. Taxicab Business Name (RI r:kl.11RI .A
."9
5. Prior experience intransportation aurllunvsa�auToTr,o°s_ eve &"s mAt�
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? ....,,
-Np_L r?(cffense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the lank five years?
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other _ - ,m a
8. Has your drivel's license or chauffeur's license been suspended or revoked in the (last five yea¢n ?I ..._..
........................................................................
ryp of af[eM_q Where When
IA
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
DEPAPtTVIIEN'Tf OF CRIMINAL IINtlPESTBt•AII]ION (DCI) I$JUnPOM” AND STA"rE CSIRTiFIE11)
DRIVING RECORD ISI&.UST ACCOMPANY TH M APPLICATION FOR POLICE CHIEF F REVIEW
You imnuust apply for an individual Department or Cirtrnlnal Ilnvestlgaflon Report Qrorm available unpon request).
(SECOND PAGE FOR IRll'2 UiRED SIIGNA'ruIRE AND NOTARY)
APP11ICA1"0N 111:011:::t .IrAMCA�I�:i�I Vfi l I111CLE ug IUVE11111
Page 2
hereby ce ity that I hrpve issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
L am• issued on �� ' <, expiring on - ZjZ C S . 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,
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)
....._.. •..:.............� . ...:........................................ __. Date_.............................................
Si nature of A icai aR........ ". , :
9 rap 9^°° .. ............w.......... _...............
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn
a to before me by .. this ` :.. .......,. day of
.� :.ti
r
Wim
.:; .;
i4C&hiey)f
SignattU of or designee
AI TIED APPROVAL BY'll'i- E MY CII..ERK YOUR AIME AUTII ORIZED TO IDRIVE A TAXICAB IIN II0WA CITY 11:::OR NO
IINfDRE THAN ONE. YEAR II::ROM "I'I11 DA"II"IE Lig"I"IED BEII...OW.
lfi lE EFf I EarlVE IDXrE WILL MATCH °lu°RIE, CHAUFFEUR'S I...ICI INSE I NPIRA'riON IF LES 'ir1UAN A YEAR.
SigSignat of 6ity Clerk designee f
EBMIMMA
Approved application
DC! report
State certified driving record
Website update
Dasic
Clerk(rAXIDRWADGEAPPL92014ammded.DOC 02/2015
02iFeb.24. 20155 9:05AM
Div of Criminal Investigation
DCI IOMNo.1566 P. 1/1
M
STATE OF IOWA
Crina ul Hhto y Record Check
RequestForm
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I AM= Number—M.-Fe-
DCI
berJ '
PCI WOGWY)
As of 7"" 1 , a wanh of the psovided nwc and deft® of birth rovoolod.
01 NO IQW& Crt lnmi Malwy Record found wch JDCI
0 IOWA CrknhW Ht®tory Rc=W a hods DCM
I ` °dale
Received Time Feb. 23. 2015 11:59AM No. 1509
/ A/ 4'iNllJ If
DOT
www.iowadotgov
Offte of €aVF Serqces
6'O Dok , ° Des Niol€rrs, IA 50348-92.04
PnWe: 8(#D 32-1121 (.Fay 525 "Ln%.107
Inquiry Date. 3/5/2015
Name: Johnston, Zachary William
Address: 1103 HOLLYWOOD BLVD
City/State: IOWA CITY, IA 522407047
Mailing Address: 1103 HOLLYWOOD BLVD
Mailing City/State: IOWA CITY, IA 522407047
Certified Abstract of DrdvifiNg (Record
DL/ID #:
769YY8452 (IA)
Customer #:
3605007
Class:
D
ID status:
EXP
Audit :
8894091
DL Status:
VAL
Issue Date:
03/05/2015
CDL Status:
None
Expiration Date:
08/19/2018
CDL Cert Status:
None
Endorsements:
3
CDL Med Status,
None
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
8/19/1983
Supplement:
Sex:
M
Citation DDIm
Convi_Uon Date,m
....Y......,...........
ACD o_n.,,
I_3
027_/2_1.1.
04_/_08/.2_1
rv106/24{2013 _
M.2_.._....E.,_xpla_n...a..t..i_..._.,....._"____.__�...�.,...._.
;Fail to Obey Traffic Sign/Signal
...,......,.C.ro...u..n._; _r..w.a..____..I_U
Johnson
m_..._....
UA
OS/Y4/2013_
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'S92 .Speed TM
_
iJo_hnson
€IA
03/21/20Y4j04/28/20Y4
_ _ _., ��
�jJohnson
IIA
Dat,-?
Data:? Caere Number
Efii7ectiv.: End .. .. �: ID.. Explanatlon ftcufr eta JIUIR 3UR
LH&b/W�a/'?CD14 411 JI/G.U6/20 P.+N F.9 n9 .... ,Novi Pavmpritjif, Iowa Hne IIA .......... 73A.._..
Name: Johnston, Zachary William DL/ID: 769YY8452
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the
custodian of the records held by the Office of Driver Services, that this 1s 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:
®E9ulfy�
3/5/2015
D O.1
ry �r
Office of Driver Services -
Iowa Department of Transportation ,
Name: Johnston, Zachary William DL/ID: 769YY8452