HomeMy WebLinkAbout14-110410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First
1. Name
Authorization
Number
(Office Use Only)
l6✓F,5 ` l_0 •
Department
between 8 a.m. to 3 p.m., Monday — Friday.)
-------------------- __
2. IMatllingaddress
3. Telephone: Home
4. Prior experience in transportation of passengers:.,-----------------
---
______________..
x
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Tvoe of offense
Where X17
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? 0/U
Where When
7. Have you been convicted of any traffic offenses in the last five
Type of offense p Where When
.............°. . .......................................... .... v . A"�.m rAd
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ pu (>
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)
r •; • •, r •
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iiiiiiiiiiiiiiiiiiijiillilli��iiiI Fill,
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
d.dd=drwbadg 0312014
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
/t_ C p= P `tri . 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)
Signature of Applicant.. Date �j
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.
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 2 -gyp (A_(...a, _ 4..._r_a. C� On this Iwai""'" day of
LA 4
Public ir`6nd for the State
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deters
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).
4
Iw................................................................................
Signature of PorWChief 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.
Signa.0 of Citya
T
Clerk or designee
477DZald-�K—
Taxi
cab businesses are required to provide Driver Identification cards. Cards must be 8%1' (width) and 6 %11
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
03/2014
o4/Apr. 21, 2014111:35AM ' Div of Criminal Investigation DCI ioa&ko.5054 P._2/4
STATE
Dintina1 Hbtory Record Chock -v
Request Fom
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No Iowa 1 r$as Incl MtoryRecord found wfth Da
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Received Time Apr, 11, 2014 12:40PM No. 5619
Inquiry Date:
4/22/2014 DI ID #:
127AC8472 (]A)
Name:
Laskowski, Joseph Waiter Class:
D
Address:
B36 WALNUT ST Audit #:
5981226
Office of Driver
Issue Date:
05/15/2012
City/State:
IOWA CITY, IA 522403340 Expiration
04/25/2017
Date:
Endorsements:
3
Nailing Address.
836 WALNUT STRestrictions:
Corrective Lenses
Date of Birth:
4/25/1973
Mailing City/State: IOWA CITY, IA 522403340 lgma
N
0PrQ
History Information
t oinlrletiion Date e„caT
Customer #:
5231945
ID Status:
None
DIL Statum
VAL
CDIL.Statura
None
CDL Cart Status: None
CDL Med Statuag None
Restriction None
Supplement:
aralpllanarWn County A
;m'us'ed^ , ...... _... .tlrtalhnson 1P
„ _ a
Cavae Number
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
;ICIIW'4
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa thle
4/22/2014
4/22/2014s
Office of Driver
4/22/2014
Iowa Department of Transportation
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
Page 2 of 2
4/22/2014