HomeMy WebLinkAbout15-036� � A
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CC OF IOW' iA E
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (Ild'Ii,SQq.PUREllf:)) .
DEN FIRCATqN.
(Office Use Only)
"
I R 1 e L 1 I �."�IN ��VI "�¢ IiiU "/P�jli /.,�6J' /VPf,0 / Iet��( lei V/dl I t"Y�' �r (ll �,�C r"I�tr <'I iLtl Ul l{ uAW
2. Address IIf G�YatioM'JI( EID" ®r�(Allrwrittenro��munircatlo serf
3. Contact Information (fI11 a UU uRIIvF'ICYy Email: _ 4Lk6 ti•& a� a.ay Cell Phone:
via email)
4a. Chauffeur's License expiration date (RIlIQ41ill U ll9) G(
b. Taxicab Business Name (IIwII,;;,G.,81111f11 IU) �tv A�. A t
5. Prior experience in transportation of arsse vaa�RAh`'"f�rm^( � �unwf C,
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
cfc
What happened to the charge? (Circle one)
Convicted 1Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where When
u �7....06L �
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended AQur)"R`kau!N Mier
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? , ......3(a
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 names)
DEPARTMENT OF CRIMINAL IINVIESTIIGArIDN Ill Il SAND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THliS AIPIPLNCA'll ON l POLICE CHIEF REVIEW
You must alplplly for an Individual Department of CiriiirniirnaR IlnvesUgaUon Report (form available unpoua request).
(SR:::C0ND PyifuRli;: FOR RREQ UlIRRED SIGNA'r UURE AND NOTARY)
0212015
AIFWIII"III.. ICA "IYII'YDN IWmf'pIW'l TAMCAWE Yt'!;:IW°U9CI..IE IDIIUIUYII:III1
Image 2
I hereby cern that I have issued to me by the Iowa Department of Transportation a validChauffeurs license number
(o `i 4 tOss0 I issued on -zlt<, I \3 expiring on ti hck 12 -al. 1 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___9Ak' /t Date , 123 ( 6
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by _ r. t" on this day of
� r w,
., ,,., .,
residentsor welfare of City of Iowa City (Title 5, Chapter 2, City of the e
Sigi —1aguiu�o Iaol�ce �[e;fordesignec
Date:
AFTER APPROVAL. BYTHE CITY CILERK YOU ARE AUUTNORII2EICD TO DRIVE A T IICAN IIN (IOWA CIITY IFOR NO
(WORE "I THAN ONE YEAR FROM " HE DATE LISTED IfilF. LOW..
THE IEI"11:'1IECTIYE DMIE WILL MATC11•11 "II"NII® 014AUII'-'II'°EUUIR' S ILIICIEINSI1E II'®XIMIfM 11ON IF Y_IESS "IFHAN A WAR.
Signat,re.of City Clerk or designee
Office Use Only
Approved application
DCI report ......
State certified driving record
Website update
........, .....Z"` ..............
6Dt
ClenrrAXIDRNOADGeAPPL92014emended.DOC 022015
mi
DOT
^ a Ia TI i=a ).c 9 UfQ f. F l r" m�f Ivivad,.�t � )v
q P
i'f�RX M.� GIMVY O✓
office of DI'Is M services
PO Bok 99204 ; Des Meows, f/5=.W 306-92U
Thecae; 515 244-9124 ( PC,W 532:..t 121 ( Fax; 1515-239-2-83./
wwmiawaadol gov
Inquiry Date:
2/21/2015
DL/ID #:
608YY6801 (IA)
Name:
Kaim, Nikita Andrei
Class:
D
Address:
320 2ND ST APT 129
Audit #:
7118031
Restriction
None
Issue Date:
07/10/2013
City/State:
CORALVILLE, IA 522412657
Expiration Date:
11/18/2018
Endorsements:
3
Mailing Address,
320 2ND ST APT 129
Restrictions:
Corrective Lenses
Date of Birth:
11/18/1973
Mailing City/State:
CORALVILLE, IA 522412657
Sex:
M
Customer #:
2110531
ID Status:
None
DL Status:
VAL
CDL Status:
None
CD8. Cert Status:
None
CDL Mad Status:
None
Restriction
None
Supplement¢
wll£,w"'RlIon !Y.bv^.IGo ti:,P.onsAc'tw't nate '10) I«'„T,alI natinn
tB"9/Qb8/7QPV3 -. .._ ,...._... Oa&/QD8/201. & .._.,., �-• IC07 ,Naa Clhdllld IFkasG!rtatlutff_..
FAcddent[ (Date
OIl/23,��'11 V4
Name: Kaim, Nikita Andrei DL/ID: 608YY6801
Use V"Umber :4IIR
HE
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 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:
......A 64 2/21/2015
Office of Driver Services
' ®§ Iowa Department of Transportation
Name: Kaim; Nikita Andrei DL/ID: 608YY6801
Shah, Of afrimm
quuetI ng aarca Iowa aax oaauraural history iecoird.. ahcck on:
.r'alsl, NaIImw 4pea6FadY enuxmriaiantup�"w•'p II llIllC'a(. Iraq I"am". M'xarorarr lJmastrfia ev
.......... ,....._ _ _... _._._.
DVaIt$p 0 I'BriIN"th Rec"TaMB e;rcpprewlo(nvmrSaimy) G6;,11!51��0",rGpavo
ale
aiver liisoat a re, Fwhna (llG Piia Keauevt m on vmuulielL okr e "u'Gv.
7 Vl'^eniamle
Fill in all shaded areas.
Mildd lle l mtll 'V(pe ,S'"v„rwrnncdva 1"7prrsSzret
rw umn s mvuerrnaza Am,, v nv c
Results
As of �M ,. a name and date of birth check revealed:
No record found
�PRa°z.aard attached DCI #
t1 -j iniliia lls�h .."
Rf"l diet
Number of requests x $15.00 per last name = Total amount $ l 6 a 0
Method of payment: ,- cash money order check #f
Cardholder's name
DCI Initials 49 -
Credit Card #P Exp„ Date
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
occusebtrr..v
MasterCard or Visa
(Last 4 digits)
IOWA CRIMINAL HISTORY
NON CONVICTION
r
DCI:00441486
NAME: KAIM,DAN
RAIM,DANIEL P
EAIM,NIKITA ANDREI
DOB SEX RAC HG'T WGT EYE
'19731118 M W 507 201 BLU
ADDITIONAL IDENTIFIERS
TAT LF ARM
CCH RECORD ***
HAIR. SKN POB
BRO FAR FL
O1 ARRESTED 19991024
AGENCY: IA0520100 CORALVILLE PD
CHARGE NO- 01 IA STATUTE IA708-1/236-2
DOMESTIC ASSAULT W/INJURY
TRK#: 035763401
COURT DISPOSITION
AGENCY: IA052015J JOHNSON CO DIST COURT
COUNT NO- 01 IA STATUTE: IA708.2A(2)(B)
DOMESTIC ABUSE ASSAULT WITHOUT INTENT CAUSING
CHARGE CLASS: NON CONVICTION
TRK#: 035763401
SENTENCE DISP EFF DAT
DEFERRED JUDGEMENT 20000218
COURT COSTS 20000218
PROBATION 1Y 20000216
DISCHARGED FROM 20000918
DEFERRED JUDGEMENT
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION