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Home My WebLink About15-073I .;�.®4 t �Iq �III;� 'rte.LI 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa S2240-1826 (319) 3S6-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. _/ '� --D 1 (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 ofthe application 3. Contact Information (REQUIRED) I IMA l i' o n 11y'C/.. Email: DUS+l, -/�� (All written comm 4a. Chauffeur's License expiration date (P b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of ps IOyatJR,rC Phone: 1 sent via email) 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed D er d Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? When 2t-),- What i7r Other When -13 -11 What happened to the charCircle one) Co Eli c d Dismissed Deferred Suspended Plead Guilty Other 8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? Where y4 When z(DrI 9. Have you ever applied jo be an Iowa City taxi driver using a different name? If yes, please provide the name(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply f6r'an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I he eby ce that I have issued to me by the Iowa D pa t f Transportafon validauffeur's license number y (L ni2� issued on � L�expirirr on 77-11, I understand that if I falsely answer any questions in this application, that this application may 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 relatin 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 theergvisjons of Title 5, Chapter 2, of the City Code (Needs to be signed in front of a Notary Public) Signature ofApplicaAKWIL Date xkkxkk<***k******x*k******k**k*******k******************************M*kh+<ko****************I11�*4:*1*Y:*****+**'*Y'*�a**+:W***o-***I****4*********. STATE OF IOWA ) COUNTY OF JOHNSON ) and sworn o before me by "�1� $1 v1 2 l4 Z on this , �C)-tA day of 'v�Cq I 1 VIENOY S. blit in ar(cl for the State 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). CXV4� Sig na ure of P` i e Chief or designee Date 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. THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR. Sign e of City Clerk=or designee Approved application DCI report State certified driving record Website update Office Use Only Date 6da� 3 1 1013 Grey c)VrLq Cit;_ In Clerk MIDRIVBADG[ PPL92014amended. DOC 02/2015 AIowa Department of Transportation Of(ioe or umilx S+-rvtves (Toll P ree) aI SI 53 " 1121 P4 U0% 9204, U@s Muinos. W 503 -'3Z94 515-244-91124 O F "i}t_ 515-23,9 157 Certified Abstract of Driving Record Inquiry Date: 3/20/2015 DL/ID #: Name: Mazgaj, Dustin Roy Class: Address: 1913 FLATIRON AVE Audit At: 05/20/2014 CDL Status: Issue Date: City/State: IOWA CITY, IA Expiration Date: NONE 522405961 None NONE Restriction Endorsements: Mailing Address: 1913 FLATIRON AVE Restrictions: 1/23/1990 10/24/2008 Date of Birth: Mailing IOWA CITY, IA Sex: City/State: 522405961 Convictions 134CC8201 (IA) Customer #: 4544774 C ID Status: None 8084063 DL Status: VAL 05/20/2014 CDL Status: More 01/23/2022 CDL Cert Status: None NONE CDL Med Status: None NONE Restriction None zone Supplement: 1/23/1990 10/24/2008 S92 M Linn IA History Information Citation Date Conviction Date ACD Explanation County JUR 07/18/2008 08/27/2008 592 Speed (10 mph & Benton IA under in 35-55 mph zone 10/08/2008 10/24/2008 S92 Speed (10 mph & Linn IA under in 35-55 mph zone 12/11/2008 12/30/2008 S92 Speed (10 mjmph Linn IA _ under in 35-5 zone 07/28/2009 08/24/2009 S92 Speed (10 mLinn IA under in 35-5 zone 04/24/2010 07/16/2010 M14 Fail to Obey Traffic Linn IA Sign/Signal 01/29/2011 02/17/2011 M14 Fail to Obey Traffic Linn IA —T� Sign/Signal 06/26/2011 06/26/2011 07119/2011 07/19/2011 592 Speed (10 mph & Washington IA under in 35-55 mph zone 02/06/2013 03/18/2013 S92 Speed (10 mph & Iowa IA under in 35-55 mph zone Name: Mazgaj, Dustin Roy DL/ID: 134CC8201 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: 3/20/2015 IOWA `N91 D. a. T.." - - Office of Driver Services Iowa Department of Transporation Name: Mazgaj, Dustin Roy DL/ID: 134CC8201 '2 3. 2015- 1:12PM Dlv of Criminal lnvestlgation No. 3 13 5 P. 1 n u i• L V, a V I) 1 1. TV MA u 1 1 y b I C I K 1. I l y u I 10 M a 1, I L y w o. 91 t O r. STATE (BY TDWA OrM4W Moorey IR i c4 II Check E- Kzi ' eu I r I Form' rt�•. u1 yrs �.,' �g6nl:rtaclsy?i �dJi{�Ir r o .. To. Iowa 1DYvIs101J of Criminal Ynvestigatton Support OperatiouaBuleau, r'Floor 215 r;, 7'h Street DesMotuesJowa 503Y9 (515) 725-6066 (515) 725-6080 )Fu. l am reauestin a an DCT AccourttMinber:6'l, bis - (irappllcablo) r From: C3yoflowa City City Clerlt'a Offlca 410 $, Waahlugton Straot lowaClty, IA 52240 Phone; 319.356-5041 Fax! 319-356-5491 I�4Bd 17am0 (Mmldalmy) 1 w1rae Plaine (n,andatoM • ' I Mttldle lvame (rewmmicndadn I I'I0.2 Date of Birth (mandelo ixelldeer (InmdalO Social 88 curl(y Numbe)f r: commclidcd) Waiverlr(formal'ion: Wllhont a signed waiver flmn the subject oftho reguesf, a completo criminal history record may not be releasable, per Code of Iowa, Chapter 692,2.1,1'01 complefe crlminal history record information, as allowed by law, always Wndveylleleuse: Dhereby giv0 de on farlhealavarogti Yngomcialto wnducfQ lDWa criminal hislary record check Wlh the')"I'On ofCrlminal tnvtSl(gelloll (C)CO, My uiminal ldalaryd to nc roll melAplll mAinlained 6y the DCI m aybo raleamd asollowdlylatw. Waiver Sidnnfure: to vr� vaa ,. ,.��,.va uew�vvaw vivaoiu,I{,, gE4Aba \"w 4Ja dilly) As of 3 a search ofthe provided name and date of birth revealed; 13 No Iowa Crhninal Ilisloty Record found Adth DCI Iowa Crirninal Histmy Record attached, DCI # C8 DCI initials__ -- Received Tlmel;Mar.20.02015 11:44AM No. 2980 Mar,"23 2015 1:12PM Div of Crlminal Investigation ADDITIONAL IDENTIFIERS �LN9�Uc[KH:Ufiii 01 ARRESTED 20090604 AGENCY: IA0570200 MARION PD CHARGE NO- 01 IA STATUTE IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE TRK#: SA006ECOI COURT DISPOSITION AGENCY: ZA057015J LINN CO DIST COURT COUNT NO- 01 IA STATUTE; IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE COURT CASE ID; 06511 SRCR003539 CHARGE CLASS; NOW CONVICTION TRK#: 5A000EC01 SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT DEFERRED JUDGEMENT lY 20090910 PROBATION lY 20090910 DISCHARGED FROM 20100311 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION 15 NOT AN INDICATION OF OUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNXSHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR TNOUIRY, DIV/ISSIOOONN OF CRIMINAL INVESTIGATION No, 3 13 5 P, 2 IOWA CRIMINAL HISTORY DCI 00869031 NON CONVICTION PAGE 1 OF 1 DATE PRINTED - 2015/03/23 ➢CI :00869031 NAME: MAZGAJ,DHSTIN ROY DOB SEX RAC BOT WOT EYE HAIR SKIN POB 19900123 M W 602 220 HAZ PRO VT ADDITIONAL IDENTIFIERS �LN9�Uc[KH:Ufiii 01 ARRESTED 20090604 AGENCY: IA0570200 MARION PD CHARGE NO- 01 IA STATUTE IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE TRK#: SA006ECOI COURT DISPOSITION AGENCY: ZA057015J LINN CO DIST COURT COUNT NO- 01 IA STATUTE; IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE COURT CASE ID; 06511 SRCR003539 CHARGE CLASS; NOW CONVICTION TRK#: 5A000EC01 SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT DEFERRED JUDGEMENT lY 20090910 PROBATION lY 20090910 DISCHARGED FROM 20100311 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION 15 NOT AN INDICATION OF OUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNXSHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR TNOUIRY, DIV/ISSIOOONN OF CRIMINAL INVESTIGATION No, 3 13 5 P, 2