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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240- 1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. /51-b-7 q
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Failure to complete the "required" information will result in denial of the application
1. Name (REQUIRED) a'l(-, jk`tll
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email:
-330`-�,�,j
(All written communibation sent viaikmail)
4a. Chauffeur's License expiration date (REQUIRED) q _,:� 4 - I :s a✓
b. Taxicab Business Name (REQUIRED) Cc �J n
5. Prior experience in transportation of passengers: cc= -/j-
6.
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? I
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where
'ar;; 3 1 2015
What happened to the charge?(Circle one) f r
vC y Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Tvpe 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 name(s)
rl--,
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I here y certify that I have 's ued to me by the Iowa Depa me t of Transportation vali Chauffeur's license number
3 c5 of `i c( `z issued on /rexpiring on 25 I understand that if I
falsely answer any questions in this application, that this app cation may be denied. 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 f Title 51 Chapter 211, f th City Code. (Needs to be signed in fr nt of a Notary Public)
Signature of AlA,—Q— Date 3 1�
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by mss` on thisJi it day of
IkAa.-- -015
WE DY S. MAYER
c;oNw*w7272W
mmiwoo 2E Notary Public in and(for the State of lowief
7 ' —i o
I have reviewed this application, DCI report, and the State certified driving record of this applicant and ldetermined°that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resk
dents of the City of to City (Title 5, Chapter 2, City Code
, iW 3 1 2015
Expiratiorf✓date !�P�uffeu)r s license+—�J�/j//
or designee 'bate!
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Signatu of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Ci.M/ IDRN6ADGE PPL92o14.�o,,ded.DOC 0312015
oaMar. 13. 20115, 1,: 47 PM cabD .V of CrlrrinaI Invesligahon
STATO OF •
Criminal History Record CheckRequest Form
To: Iowa Division of Criminal Investigation
Support Operations Bureau, V Floor
215 E. Ta.Street
bee Molnes, Iowa 50319
(17111) 725-6066
(515) 725.6080 Fax
T sm remravrino an YA. . ri.l...l«-r Tvt-.__. n ____J nL__r_ __.
(FAX)3193392N �,; 2440 P. 1„11/002
DCI Account Number: 9967-F
(iropp0e611)
Fromt 'Yellow Cab of Iowa City
P.O. Box 428
Iowa City, IA. 522d4
Phone: (319)338-9777
Fax: (319)339-7302
Last Name (mandato
First Name (mandatory)
Middle dame rewmmend
it
Date of Birth (mandato)
Gander mandato
Social5ecur[ Number newnmended
g
,/
❑Male LU31"emale
Q -d
Wai' er-1 f019Natlon. without a signed waiver from the subleot of the request, a complete criminal history record may not
be releasable, per Coda of lona, Chapter 692.2. For co=1010 criminal hhtoryrecor(i information, as allowed by law, always
obtain a waiver signature from the sub eat of (he requesL
Waiver Rdlda5di l hereby give permie lon ror the ab o a reque II omllal to eonduol an Iowa trim' ai history record checktvllh the Division of01minel
Invailgatlon (DSO. Any erlm(nal hluory due conte in o Ihat is malntoined by the W1 may b to eQ al ailmyod bylaw.
WalvdrSignaf •— —
.ay..r vA aau■a•u■ AAAMaUl Y iXOL:U1LL %iJ10L:1C-MC,3ULLN (DCl we only)
I
As of 121/3 , rl a search of the provided niime and date of birth revealed:
V
No Iowa Criminal History Record found with DCI
/❑ Iowa Criminal History Record attached, DCI 9
DCI initials
DOI-77 (08/25/10)
Received Tine Mar. 12. 2015 11:2BAM No.2849
NE1111103/31/2015 13:06 Yei low Cab of Iowa City eFAX)3193382:08 P. 001/002
S}
^- Iowa Department of Transportation
pp office of Driver services (Toll F(ito) 80-632-11121
PO Box SEW, Dos MdnBs, IA 503060Z04 515.244-0124
FA)L 816239.1837
Certified Abstract of Driving Record
Inquiry Dntel 3/12/2015 DL/ID 4$t 838YY9949 (IA) Customer q: 3912615
Name: Kane, Kourtney class: C ID Status: EXP
Kaye
Address: 115 HOOVER BLVD Audit ir: 7196661 DL Status: VAL
Issue Date: 08/01/2013 CDL Status: None
City/State: WEST BRANCH, IA Expiration Dates 07/13/2018 CDL Cert Status: None
523589405
Cndorsements: NONE CDL Mad Status; None
Mulling Address: 2401 HWY 6E API' Restrictions: NONE Restriction None
4010 Supplement:
Deter of Birth: 7/13/1984
Malliny IOWA CITY, IA Sex: F
City/State; 52240
History Information
Convictions
Name: Kane, Kourtney Kaye DL/ID: 838YY9949
Pursuant to Iowa Code §321.10, 1, 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 Offlce 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:
3/12/2015
IOWA '!� of ar OF
d�ilrc�
Office of Driver Services
Iowa Department of Transporadon
03/31/2015 13, 06 YeIIow Cab 0f I0Y1a City (FAX)3193382708 p,002/002
Name: Kane, Keurtney Kaye DL/ID: 838YY9949