HomeMy WebLinkAbout15-052;f-"ux`urr`aV,+IWAN
urw�"af�
'wx�� I/�NtlM1§OUA 11i,n11. W 'µ
CITY O IOWA QTY
0
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Namegl='.I,;r"U-illfi I'::r)
u( EN'I 11FICA IC KM NO, / -,IDS ,:111 .....,-
Ifnnx.. � Lase rou,y)
A&IIPII FOR "I"A MC,4B d MOTORIZED II�N"DICAB VEMCILE I1 MV ER
(Pollce Department i evuew, must be irnade between 8 a.m. to 3 Ip.m.,, IMo nday .._ If'irrtday)
/------
.,e„�,e, m, 1/e, jllJJ 1, Jli lil lll�
I`h-M
.
2. Address
3. Contact Information EkJII I)r NwnnaMll: .() ..�
M Information
( t�� � n fl° G callll 11 uMur uuas 4 �Y M, .......
(Awirittel'n ) 4 i nl'TRIJllrnlicatlion arae nf', Aa 4'Y"i alll)
(RI date expiration 4a. Chauffeub. Taxicab Business Name (IZEQUUlfl 111 ,,-, t II
Chauffeurs License ex r;11,U I U
P
5. Prior experience in transportation of Irps„se purger ....,,,,,,
6. Have you ever been arrested/ charged with any rnuPsaMernne:anol s and/oir fellonIies In tl niis State or elsewhere? Y g
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other -
Have you been arrested / charged with any traffic offenses in the last five years? ____-7 7T
Typoorasl;;frnaf Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Gutty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last rive years?
ype of offense
Where
MM
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
II:DBPAhRTMyMBN"If OF CRR MMINM... INVfN'::;S'71GAVTM (DCB) REPORT AND S'Y' ATIB CERTIPIIr'I:D
DRMNG RECORD MV9Ius r ACCOMPANY TRIMS ARPPLICA MN II::'OR PV;DI_ICE CHEF REVIEW
YOU rrnus't apply Voir an IrmdMenGduueV Department of Criimminuall ttivesfMgadan Report. ((form avaulabte iupon request),,
(MEC01141) IPA4GE II::OR REOU1114 E D SIGNAI"N"LDRE AND NOTARY)
MKOW
A0�'"MmmIC..WSA"2p�p1N II1°f:tll::t "'m"AMCAB Vll'ii��EIR10E..JllE, IID111"1lPVllEll'F
wags;, 2.
consent e r allow agents or employees _ City of * w. City, Iowa,discretion, . examine a * all recordsand
,, ♦: ♦ ♦ +M.• * -� *1.^ "1 0 Bei
Signature of Ap /nom � i , •
STATE OF IOWA )
COUNTY OF JOHNSON )
r -� ,.., iII IVyK.'VUA II""II II Igg _.��. , _ day of
nuulP n o� red and swoon to before me b � �t 1 & p¢ a � r" on this
J� . d�
a ;r ..ry ^ iai,uhui 221I 1 9� "iota: ry l:lulblic in and 'kn tho „"iat'o of lq,'waa
oliq
rolmn Kim, ,.
or welfare of residents of the City of 1, o
Signet Poli ief-o?designee ttaVu,
AFTEIIR APPROVAL II3Y TIME® CVTY CLERK YOU ARE- AUTI-IOMMID TO V RAVE A TAXICAB IIIM IOWA CfTY FOR INO
M4ARIE Tl --IAN ONE YEAR FROM "I'ME IDATE ILIIS"MID BELOW.
THE EFFECTWE DATE. MLL mA.TCH "f HE CHAUFFEUR'S LlCE'NSE E PIRA f aq IF LE.S a THAN A YEAR.
uw'"P w"w!ryw,,.y a .._
Signature of City CWk or desiignee, 11"atn
Approved application
DCI report
State certified driving record .,,.,...,,.
Website update
ClerklrAXIDR[VBADGEAPPl92014=.nded.DOC 02/2015
m/fA
ry �j VA
f i� : i
r W
I�
DOT
SMARTER I SPAPLER I CUSTONIEF.
y�
ty�t4 8—
Of
Of Age of T' nvez:Sdra'm ms
PC r3oy,. ' Des IsO( ws, n , ' .wi'a21x
PhorrArrl: $15-244-212si C 8DU „"iNA 121 f r mr 546-239-107
Inquiry Date: 2/27/2015
Name: Shaffer, Dustin Glenn
Address: 4760 MAIER AVE SW
City/State: IOWA CITY, IA 522408416
Mailing Address: 2551 HOLIDAY RD APT A4
Mailing City/State: CORALVILLE, IA 522412782
r
C'&taw:km ]Date ConWc'tiion Date
DL/ID #: 961AA1261 (IA)
Class:
Audit #: 7793710
Issue Date: 02/14/2014
Expiration Date: 02/08/2018
Endorsements: NONE
Restrictions: NONE
Date of Birth: 2/8/1990
Sex: M
History Information
ROM
Insurance S..aEd
Customer #:
5145452
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
County .JUR
lohinson 1A
Accidents tii,.,,.
F.cddent Oaks Case Number 3UR
Op987 a92D.tl 2 '680406 <rc m
Name: Shaffer, Dustin Glenn DL/ID: 961AA1261
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 tI
custodian of the records held by the Office of Driver Services, that this Is a true and accurate copy of an official record currently In the custody of sa
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:
VidlClf b l
2/27/2015 ..
IOWA `&
SBIVE* V
Office of Driver Services `
Iowa Department of Transportation
Name: Shaffer, Dustin Glenn DL/ID: 961AA1261
M/Feb. 20. 2015o 4:11PMCam Div of Criminal Invest,gation (FAx)3193382No.0800 P...1/l/ooz
fi1§
STATE OF IOWA
CriminalHistory
Record
Requestyr
To: Iowa Mylslon of criminal lnvesagailon
Support Operations Buroau, V Floor
21S 8. T" Street
Das Molnes, Town 50319
(575)725.6066
(515)'725.6050 Vex
DCT A ount Numbar6 —9967-r,
From: SreBlor� Cab ofYOuv� C1ex
P.O. Box 428
foWa City, 52252244.
(319) 335-9777 —
Phone:
Fax: 19) 339-7302
No Iowa Criminal History Record found with DCI
EJ Iowa Criminal History Record attaohed, DCT # __
DCI init%ala
DCI -77 (08125/10)
Received Time Feb. 19. 2015 3:10PM No. 1337
(DG oro only)