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Home My WebLink About14-144Authorization Number_ 2 1 r 1 (Office Use Only) 1 UIIImast 7 • ® F pts Of CITY F IOWA CITY APPLICATION FORT If OTOR EDPEDICA ICL DRIVER (Police Department review must be made 410 East Washington Street between 8 a.m. to 3 p.m„ Monday— Friday.) Iowa City, Iowa S2240-1826 (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name _._ .,x_.._--...... _. �.fxF.., a 2. Mailing dLCidresa, ......�'...a........::�...... "^aaa'x'.J.�... ..`".�............ h..::... ._ °??•-...m.. ._...._®._ _-_........._.........__.....__..............®........_..__...____ 3. Telephone: Home L\a�-Z la Other: 4. Prior, experience in transportation of passengerr.,r . �L jLg Q ft qy p � � 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Ob Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? P'b e of Offense Where When ...�:"1..qq.��.; WAi .. pT.•A,,�m»�.,� R.w.U`... tl..:x M1m.1 & ,Xq ` y ....................................... ............................... 7. Have you been convicted of an traffic offenses in the last five years? Type of offens Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? K5 Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) •' •-• • • i • •• You must aDo . •., , , (OVER FOR REQUIRED SIGNATURE AND NOTARY) ` Mmd&orb "Q 03/2014 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chautteur's license number._. w,Q w#. '"" """IX I understand that if I 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public c Dateµ,. m % Signature of Applicant- _.. _,_,_, YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERICS OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. STATE OF IOWA ) COUNTY OF JOHNSON ) and sworn to before me b 'tl OA . "� rM ¢�_ . On this Y .. .......A;..?:....:.aA�:..a��..... day of Wt' NDN S. ry'Pive* r, 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). d4'g21A1Y- Ir Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERKS OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. Sig'natur"p, of City Clerk or designee D- -_ Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 5'/d' (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update deftUAdrMmaaeapP2014.doc 0312014 NKD7,ulu1.14. 20142.Q_56AMca6 iv of Criminal Investigation STATt OF IOWA Criminal History Record Check /iRequest jForm ;Fnx>s)s Na, 4669. '.P. 1/1,-pdz "I'ea dowro DiveoPaaer orCrIMIII ea aauyeateIgotion From Yellow Cab a.flowa't:lat Suup pox°r. operatIOUJI Iuo Floor P.O. x 428 2.t5 M Tse tlte°aet Dos MMuee% kinwa 50319 4owxa Chy, IA, 52244 i3I572d.��6�r Phone: Psx® (3.I9) 3:3:9-7302 Waiver ]gform at'Maaus„ witiI o asixed wailver jhroula the deahieot of the Ivgpoaeq a eouexgrlgto Qrtrr nal IatiI I-Veor''d may net Poe rePeeeeeneek Area° Cede of Iowa, Che@neer 69202 Icor oxo Ieea ortxtpdsao7 kseoremy reeoeuY tororeeuateon„ at Wlaawod bylaw, a lwoeye Wffedtee", ele e; I homey IN ¢ blhosftTVeebw+ rgeiIe6tPePeaas§wo6eeuromBaveatPeOikmdpauw��rcveeaer�epeoPa�ppPnudetr8�po.Pee tCaCataPuieB Iov00e1I q CM Any cirbMI II daZ@WWWON 1190 ffid Ia aeikektika I N a amiuvbe Moeood iU Whm..d by hew, AR of— "],,. �t� �t ft :seam• OMO provided name and date of birth Ievaoled; No Iowa Criminal History Rcoord found with DCI r, Iowa Criminal History knord attaol'aede DC1 # P-- po DCI initials Received Time Jul. 9. 2014 9:23AM No -3879 fault or given a citation. Name: Prymek, Donna Marie DL/ID: 432YY5707 Pursuant- to Iowa Code §327..10, 1, Kim Snack, Director of Office of Driver "Seirviices, Iowa Department of rransportatlon, 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 .:algnature and the seal of die Department to be set upon this document, at, Ankeny, Loma this date: l ovp N � of !MI i" M t 1u 1or olhc u? Clwifr N Irvew rrdl FrecNOD, 512 fl 82 1 '��..... Bou 9204, arlft,IMli 1(m% iur4IIrFYJh1 02[14 u P dk.�_ 51!� J i4P Sth'Iie• Certified Abstract of Difting Record Inquiry Data: 7/22/2014 DL/ID #: 432YY5707 (IA) Customer #: 3875157 Name: Prymek, Donna Class: D ID Status: None Marie Address: 2175 KOUNTRY tH Audit #: 5453760 DL Status: VAL SE APT 1 Issue Date: 08/18/2011 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 09/23/2015 CDL Cart Statusa None 522409302 Endorsements: 3 CDL Mad Status: None Mailing Address: 2175 KOUNTRY LN Restrictions: Corrective Lenses Restriction None SE APT 1 Supplement: Date of Rirtta: 9/23/1979 Mailing IOWA CITY, IA Sexu F City/State: 522409302 IH!story :Info Irmaation fault or given a citation. Name: Prymek, Donna Marie DL/ID: 432YY5707 Pursuant- to Iowa Code §327..10, 1, Kim Snack, Director of Office of Driver "Seirviices, Iowa Department of rransportatlon, 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 .:algnature and the seal of die Department to be set upon this document, at, Ankeny, Loma this date: