HomeMy WebLinkAbout15-047mWWcum aYl A. ��• ,�
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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
1. Name (i tl,;;lQUIIREIID) „
2. Address (u:Z Q Ul l r' 1 'D:
,
(Office Jse 061y)
P� VEIL.
(PoIIice IDe artmerut review irnurst Ibe uvaade Ilse( eein 3 a�l�. 3 ME, I oridaly....Friday)
FVlat
Last
n11
)„ 3. Contact Information ( Q 1 FC( Email: CelPhone
(All writtenoomrQ nicat�i
ail)
Fa. Chauffeur's License expiration date
b. Taxicab Business Name (RI IQU11 tEIII( .. ... U f„ p..0 . ,... _ ....
5. Prior experience in transportation of lrn congers;,
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /J,;
Type of gffPnse Where
What happened to the charge? (Circle one)
m,
.- r'A "-.r i...-..
7. Have you been arrested / charged with any traffic offenses in the Hast five yeas s?
Vy(re of offense Where.
What happened to the charge? (Circle one)
$
When
mm", immsimmemgmsem
5, Hes your ddvelr"s II1boinse or chauafffeulrS license been suspended orrevoked in the Ilast five years? ........... a.:4.t"a
11 mm off ar(1knnp
Where
When
DEPARTMENT OF CRiDI CNAL lNVEVV IGATI13N (DCQ REPORT AND STATE CER.TlIFiED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR P0...lCE CHIRP N60ft6W
1rcm must apply for an lindlvldu td Depalrtarrrevrt 0' Criminal Investigation Report (to!rm available upon request),
(SECOND (PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02r2015
t1PgLK,''T"'ill"1CIIh1 F0111 "'III"'AAC'T11J' ttiTll°'II1CILg CI€IIVE111'1
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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)
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STATE OF IBtlj)
COUNTY OF JOHNSON )
ubsrrilaetl and 5Warrr to before me by _wap T T ���°� � ...., �°A �lm�, on this ... day of
� )III c uai�ud iu a �llr * , tr ll loons
Antlk'IIMMA*MMA:d MnPfl�M*J"*MisN:tirINArAIFdn'*A****M1**AA OMM YkYn*WMMM'MA N1k MM\AY,MMrMroY NIR*ahk*4N;$IkWRlFllmpdbJ'rvl6'4dAA*110'.YhN�'MH:Ik'WRd:M1kWrIRfl�M
I have reviewed this application, IM report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Signature ofPc V Chief or desPgnee
t�
F"I"I.Ift APPROVAL. 1BY "II"HIE CITY CII.."ERK YOU ARIE Ag7"I.1101RIl2i IY.:I "Ii'gl DIME E A TAXIC'AI3 III Iom CI'1°Y FCIa NO
lYlt' m "Irl I Alq 0INIl1; YEAR II Ti III" DATE ILISTED 1I
"II"II II'Ig II!!4:11::91::rEC"II"1YIE l:Irs"rl" Il..t. IIWAll"Clt THE CIIiA :11::'EUFk S IIJldlli NSl4 IIia IfPI1 A'1I"901N 11 LESS III YEAR,
Sig g
rna 8vca o' Cu t"'lleu'ic oir d�su nca:
Date
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WrAM11r-ARK14 a
CWffA7UQRI%(BADGF..APPI.92.014.ended.DCC 02/2015
Mar. 2. 2015 4:12N Div of Criminal Investigation No. 1480 P. 4/6
,... �1- 4.11J.-rvia v.iy olcla vary VI Iowa UI lr h0. 7007 F. f
CrAminal History Record Check
+,iy I
STATE %1 I V lel I,
�I
r
,i^� Request Ifylrk:
T6! law& D1081011 of Criminal Invoidladou
Suppott 1poo
215 B. 7,4 Street
Deg Moluelp Iowa S0319
6I66
;M1 Pax
an.. Tow
e -
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zq,
ACIAcoountNurnbcr: t& ..•
QFtayyaggc��6®y
From; , a" qty of.11o'y' .M 4. jk 'r—. ..........----.,.__
City Gley eff 01WA
..���P^ashgoa�oma���,• t
llabWa CUy„ fA 52..2.40
Phone: 319 3156 50 11.
. Tars 3t9-g9ty-9497
Ili
wfale tl�-�11C'orood.dw." u J & ldo � '4,..� .
..��...,............. ._........ _......................................... ,..............................................
.
f'lAass dfa &rvtdwasafdoi�s.' Withoaut a niky]"d wawar Au^oraa thm subject of dtas Verpltest. a eaamplete ew'quaa W htotmry reeorat In ay hot
taera~,togasahNeeper Cade, 0110sgruaachsaptergw 12,.ty°mw^„�,v.IroR�,etgnasflpsgUgagetaaayaceurratlaa�ml^usaatameasmnoAggauawr�Vu�Vaumv$ggww�ys
u¢N¢fafiL . auua�dnn.i- i.no«�..-.�a^.��. �a�,aA., avG_ ....w..c_..�. _R. nL- .�__...._.rc.
Mlydy fieledse. lhcrebyglvo yamllsslon fortho above rcquesllas 9115cial to coaducl an Iowa ar6ainal lushayraeord check with the Mblon of Cilmiam
ynvecsrsetlan(Doo. Any rWrialblslmydata canoamngsnaIN? lamaintainedbyilia DC1may boMaud asaltmyedbylmv.
Iowa Criminal U-114:0- �'Reeo
^^^ (DCluse only)
7.
Aa of ,.. ::, ... �.. _........ a aearch of rha provided name and data of birth rewsled:
No Iowa Crim.ftial Hismy Record fomd with De
El Iowa (criminal History Record attoohed, DCJ 4
..................................... , j
•l��"liiraiftsalua,.......... . .......
nTnq innn<no%
Received ime Feb. 27. 2015 3:47PM No. 1415
nig �
IUADOT10
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"VMW110yVadotgov
SMARITR t SIMPLER 11 CORNER
t9�rar��Of 6;ru§rmz':Tndli sBd�s
II°4.9 Bm ,X04 10162 Mbine.,% IA 913064M.04
Phone— p0Svx 2240 9124 f WD -&U-1121 l[ Fw . 515-2.33-1837
www .tSM &dot.,lWw
Ceirtlified Abstract of Driving Record
Inquiry Date.
3/3/2015
DL/ID #e
413AF8068 (IA)
Customer S.
5597450
Name.
Bod)ona, Bassal lean
Class.
D
ID Stalemn
None
Address°
431 5 SCOTT BLVD
Audit 4s
6640514
DL Stature
VAL
08/03(201.4
.BO/3012'014
Issue Date.
01/24/2013
CDB. Statues
None
City/State.
IOWA CITY, IA
Expiration
12/31/2015
CDL Cert
None
522455526
Dotee
Status.
Endorsements. 3
CDL Med
None
Status°
Mailing Address.
431 S SCOTT BLVD
Restrictions,
NONE
Restriction
None
Date of BBirtin
12/31/1985
Supplamou :
Mailing City/Slate. IOWA CITY, IA
Sex:
M
522455526
Cltatloin Data
Conviction (Date
ACD
...................... ....................................... ......_....,........... ........ .
Eanp[anattoln
... ....... .......................... .,........ .....
County
.................................... ..
Hlll8
10/261201.1
II 1,/'28/201.0,
IM1 4
IFaiil to Cbeyt Daffhc Mgn/Siiaynal
:Vulhllm;;on
IA
0/9'0.38,'2HD IB3 _
..
OB/Ol/2GD,13 ._ _,...._.
..
,a.D2
...,_.......
*�IperrR._...... .. _._.....,.. ..
..._.... Scott
.¢A I
08/03(201.4
.BO/3012'014
N50
' 4llnicropelr rurlm .. .........
.. Trtnhulson ...
._ ...
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Acc6dent; Onto
Case Nlmnlliter
1U',.uin
4au/u atuIXl
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to
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..
... .. . �IIi .. .. _
Name: Bodjona, Basset lean DB./ID. 413AF8068
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:
. .........
I(} ape 3/3/2015