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Home My WebLink About15-092CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa S2240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. J I -D O-cl- (Office Use Only) APPLICATION FOR TAXICAB I 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 First 1. Name (REQUIRED) c,Gy le 2. Address (REQUIRED) {i IMI:ti A,n Dr tyy ro, - ccs Q; yrs , LA 5a(/oS 3. Contact Information (REQUIRED) Email: Smcon5-3/�Z- y-,In,,;.rar,-) Cell Phone: 3+9-cifgil (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) A rJ// /-�O( 5 b. Taxicab Business Name (REQUIRED) _ �42.I(ovJ rr i 5. Prior experience in transportation of passengers: 1&,C1qr s r 4 rr �"4"2:A (' _ Ler V { 1 10 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?_ Type of offense As 5au,I t When L) What happened to the charge? (Circle one) onvic Dismissed Deferred Suspended Plead Guilty Other Have you been arrested charged with any traffic offenses in the last five years? ��. Type of offense Where When F�iloW,l�r too Class; io,,,-I = V What happened to the charge? Circle one) Convicte 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? Type of offense Where When N 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prthe`H"me(s) M. DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT Til DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE Ck1teF RF3111EWM cr �� zr �+,�' You must apply for an individual Department of Criminal Investigation Report (form ava ble ul regwesr). cr1 (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 5 5 0 w w 5 it 3 issued on 1 xpiring on 5/18/ 00 / a. 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 pf Iowa City, Iowa, in their discretion, to examine any and all records and documents relating to this application, and I furth r agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Title 5, Chapt r 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date 6/ a / s STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Lk -e— f'yA Of> "l on this � -4 le,_ day of i eu e k. rurne Notary Public in and for the State of Iowa t1n Lxptres 5 /LZ. I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). date Cha ffeur's license or designee Y ate 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. Signat of City Clerk or designee Approved application DCI report State certified driving record Website update ,/-/:7 Poe /oz Dat rs 7 Office Use Only70 'tom ' rn X. rim CD cn NO aen0TAXIDRWBADGe PPLs2aiaa1,.�ded.DOC 03/2015 �A Iowa Department of Transportation [YS ultinff, of Ororr 3:rriCC£ ,SeAI I fuellli}li t32 11 1 IJO BiD, m12(M, UJ 3 Mt5if1t5. �A 1,11 142,34 Certified Abstract of Driving Record Inquiry Date: 4/17/2015 DL/ID # Name: Moon, Samuel David Class: Ir Address: 2110 N TOWNE CT Audit #: NE APT 5 580WW5113(IA) Customer#: Issue Date: City/State: CEDAR RAPIDS, IA Expiration Date: 6464764 524021952 VAL 11/13/2012 CDL Status: Endorsements: Mailing Address: 2110 N TOWNE CT Restrictions: 3 NE APT 5 None NONE Restriction Date of Birth: Mailing CEDAR RAPIDS, IA Sex: City/State: 524021952 580WW5113(IA) Customer#: 3728851 D ID Status: None 6464764 DL Status: VAL 11/13/2012 CDL Status: None 05/18/2018 CDL Cert Status: None 3 CDL Med Status: None NONE Restriction None Supplement: 5/18/1984 M History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 09/25/2011 652500 IA 03/25/2015 851783 IA Name: Moon, Samuel David Jr DL/ID: 58OWW5113 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: 4/17/2015 IOWAIr D. O. T MIA Office of Driver Services 'tttr.l. a-~ Iowa Department of Transporation Name: Moon, Samuel David Jr DL/ID: 580WW5113 HPr•[3, lUl7 9:4UHivi P i v o 6 r i m i n a I Investi;ation No.h62h P. 4 F•..••^—••r C11""". b1a :9 6aiamv 04/21/2096 l3;oo lba3mP.002/002 / Jr�le nl nub, ;., STATE AOF IOWA q 6ycltt . � Iowa j Il History Record Check r;h.fc r; Form �;•.,--,:`1, • To: Iowa Division of Criminal Investigation Support Opevatlolts Bureau, 1" Floor 215 E. Ira Street Des Wiles, Iowa 50319 (515) 725-6066 (515)725-6080 flax an Iowa 5/rs/Sc/ Record Check on; First Name (mand,twy) c-,-tmvt'-1 �r DCT Account Number: co - T (ilapplicable) From: C —C& of Iowa Cit City Clark's Office 410 E. Washttr oa street lova CIt , IA 52,240 Phone: 319356-3041 Pak; 319356-5499 clvtv'.( Male ❑Female I Waiver Information: Without it signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2, For co_moleke criminal history record information, as allowed by law, always Main a watver sl nature from the subject of the reluesr. Wa"Vef 1ieiQ//Se; l hereby givo permission for the above requesting official to aonouel an Iowa criminal hntoryrscord check with the Division of Criminal Investigation (DCI). Any almf)al hitrory data wnceming me that is maintained/4 /t /DCI may he released as allowed bylaw, WaiVer,SiBrralure• < - •L� . _ n Iowa Criminal History Record Check Results (nCl use only) As of a search of the provided name and date of birth revealed: C„ cn ❑ No Iowa Criminal History Record found with DCT n • I TOM Criminal History Record attached, DCT ii � DCT initials_ r -' J DCT -77 (08/25110) Received Time Apr. 21, 2015 12:54PM No.5952 KPz,2J. 1017 N:4j,]Vi Div oT 0 imioal Investigation No. 1625 P. 5 DCI:00694606 NAME: MOON,SAMUEL DAVID DOB SEX RAC 19840518 M W ADDITIONAL IDENTIFIERS IOWA CRIMINAL HISTORY MISDEMEANOR CONVICTIONS ONLY HGT WGT EYE HAIR 600 260 BRO BRO CCH RECORD *** DCT 00694606 PAGE 1 OF 1 DATE PRINTED - 2015/04/23 SKN POE IA D1 ARRESTED 20030201 AGENCY: IA0570100 CEDAR RAPIDS PD CHARGE NO- 01 IA STATUTE IA70B-2A ASSAULT CAUSING BODILY INJURY DOMESTIC ABUSE TRK#: 502015901 CHARGE NO- 02 IA STATUTE IA706-2A ASSAULT DOMESTIC ABUSE TRK#: 502015902 COURT DISPOSITION AGENCY: IA057015J LINN CO DIST COURT COUNT NO- 0I IA STATUTE: IA708.2(2) ASSAULT NO INTENT OF INJURY - 1978 COURT CASE SD: 06571 SRCRO50284 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 502015901 SENTENCE DISP EFF DAT TIME SERVED 37H 20030830 SUSPENDED JAIL 21D 20030830 JAIL 4D 20030830 PINE $250 20030830 PROBATION IY 20030830 COURT DISPOSITION AGENCY: TA057015J LINN CO DIST COURT COUNT NO- 02 IA STATUTE: IA708.2(5) ASSAULT COURT CASE ID: 06571 SRCR050264 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: $02015902 SENTENCE DISP EFF DAT TIME SERVED 37H 20030830 SUSPENDED JAIL 2D 20030830 JAIL 4D 20030830 PROBATION 1Y 20030830 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, 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 XS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION Au-