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Home My WebLink About14-261®r .m 111 p` CITY OF IOWA CITY 410 East Washington Street Iowa City, lots 52240-1826 (319) 35 54 —F X Authorization NumberYELi(,�, _ 1. (Office Use Only) APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) aA/rna few as le8� 8/ne `°ems rvdmel"' in oapveafa0ra web/ res¢add irre clerai�l of tPtp li qn First 1. Name (REQUIRED) j L, 2. Mailing Address (REQUIRED) 1-, l �e�dd� 3. Contact Information (REQUIRED) Email: Middle 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or Where 6. Have you e nconvicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense Where 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? AA 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 Itame(s) Nib DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CEI` ,14 DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CH) RF"REvIE�w You must apply for an Individual Department of Criminal Investigation Report form availableiu ponnequesf# (OVER FOR REQUIRED SIGNATURE AND NOTARY) I h b certi that 6 ve issued to me, by the lov<<a Department of Transportation a valid Chau'ffeur's license number .. 3 Ci I understand That if 1 falsely answer any questions in this application, that this application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will 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 p visions of Title 5, Chapter 2, of the City Code. (Needs to ba signsd in front of a Notary Public) Signature of Applica DateC YOU ARE NOT VALID O DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. STATE OF IOWA ) COUNTY OF JOHNSON ) w On this 5Yj'ln day of 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 Poli f"or designee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. o n ure of City Clerk or designee ate Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 6 %" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update CleNTAXIDRN3ADGEAPPL92014am ded.000 09/2014 Dec. 1. 2014 2:34PM Div of Criminal Investigation afov, 1). zvi4 1:urrM Ualy bie/K — 611Y of Iowa a.aly No.5244 P. 4/5 No. )41Y r. L To; Tama Invisl000 of Crim laid hveattgatlon Vronna --g!W Lf Support Operations Bureau, 071cor City Clorles Offics 315.7agStreet JA01 laeingwn,Siroei__ es Molooes, Iowa 50319 ______ �--------_____ (515)) 7356066 'An a.iP� Y 5__ ___------__.: ____ (375) -6080 Psis Plaone. 3.19-a56- 5041 PORI �ti9-366-^�4.9mtt f am re uueasaVua sxr:lowa. Caix'eainal His .p.eeoNd Clnascic mu 1PaaRtNgm! iia aaarb--- ------------ ______ First a�^a�b°�b_______�--- 1_l�ie�dlln��i��aao(rraaaxarnremeeal 64VOK a �, �°� Date of Birth (Hnaadaua&q) — Gonda r (voaa4sa 1 Social Seefado numabo e (sa a, ars6a� stle �lla"eroxiaulaa r�° ��" d� ,_ i� ofP✓av It � r Adafuarra,r tlRaiBPaocut a,ai maat wrad ar frontti ti a afuit�oo@ of t$kopeap¢uasts a aeovnpiaes orfunMuaaa rafafory record ttxaaY not he roloarnbWsr pox° code ofIowa,craapter 6922..Poo orBrr RAI history neorrl klr°ormsrPenx as aifowad by Yaw, final `s obtaixaa sfla er s aa&uaro riroro ¢ffu a xQr mm@ ecr ifaa r aesR w,__---------- agver.ReroadseG A Nanta AwV yeraflsdah a°aaft Aova nr.j,=aang 6raai b randrmi a a a Iowa al M MuHOWYaooad 0W Mrh AD l vhkon ofQ616ai ivpvee6tlq"Cioa(��%N}„ its"muXutalOxCsttaeYdnY�%marow¢r.Clogwn aeMMAi; aoii cdc YdfiaCRaa b,feln d Yow•sdbyfMW' ' Waiver ftNalurd __ _________ --- 0yra I I nal flisto�° or Check m,� nae on(y� As of ._______ __ _d.�/ xr rsasre�n oftho peg aa¢ d name sax t�s'2 of birth aex� fed, M610WA, t1dna(isal'rratofyRecord foaandt ith.DC1. Iowa (`atcunaaeal yxlstary. eoord aitsohad, DC' .d _ __________—• Da Wud' Received T i m, eq Ide o .____ _---------- _------- ________-------------- _.. y: 25.1(2014 3MPM No, 5947 DOT 0M, VVWIAMI)Wadat-�gov ARTER 1 0APLER I;USTO E (MC6, III t.6aTWSell wh'egs'a e0i ift. iV.04 1;W f:fiblwir, W jaw -me U l "tt.BNID¢'". "m9a-s �'� ra�U.�+@ I�:hll"bD "irv"2-°I t✓"R I F oJc.:a"G;'p�.�(,?.4tI- 6&!4��R wauar.ta�nll;.e9avt.sy�'/ Certified Alb traet of I(IOWnig Record Inquiry IDataN 7.2/3/209.4 Dd.JIMID Mi 803ZZ2363 (IA) Customer Vu 3636560 Nameu Voumbrork, Rick Page Ciasm D :RID Statue: None Address. 150 PADDOCK CIR Audit N 6633584 DL Status. VAL Issue Date: 01/22/2013 CDL Statusm None City/Stator IOWA CITY, IA 522407201 Expiration Date. 01/09/2018 CDL Cert Statum None Endorsements. 3 CDL Med Start= None IIMallling Addneew 150 PADDOCK CIR Restriction®: Corrective Lenses Restriction None Date of girth. 1/9/1951 Supplement: Mailing City/State. IOWA CITY, IA 522407201 Sax; M ClIlfraNG11111 Ulate COMAW'.r'rueuv Date ACICV 01 xpllammat: in cros iiimty „Vtllls tlfuh-Wi6n- •tPI%3Itt,/2013 -01%3 I11)dy nq W rai 9 VIM y euu 0neWyaay bent JohiluisoIn ......... ]A Name. Vornbrock, Rick Page DL/IDN 803222363 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: 12/312WA �' se CIVASA rrw �. i Office of Driver Services Iowa Department of Transportation Name: Vornbrock, Rick Page DL/ID: 803ZZ2363 .:..