HomeMy WebLinkAbout15-099IDENTIFICATION NO. i
1 (Office Use Only)
CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 ?"2huf i'O result in a'o,7ia; of the appiicaffen
(319) 3S6-5040
(319) 356-5497 FAX
1 First Middle Last
1. Name (REQUIRED) ACsF-p q WAL_-r E2- (--0kow5fA2S
2. Address (REQUIRED) t S& WAL. ky"r ST- ToWA Gr TY Sq SA-gyo
3. Contact Information (REQUIRED) Email:tPl.cot1 Cell Phone- 3y�•59Li•z7fJ�
(All -written communication sent via email)
4a. Chauffeur's License expiration date (REQUnIRED) DK . OL 13
b. Taxicab Business Name (REQUIRED) MkYGJI'� I ar- CC
5. Prior experience in transportation of passengers: Iii Vel 6u-Ir-
A- I
u-Ir-A.. - r .j_
6. Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsewhere? Nv
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested/ charged with any traffic offenses in the last five years?
a
Type of offense
r r y "�
c7�
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended ead Guil Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Tvpe of offense
Where
When
E5
Ala
9. Have you ever applied to bean 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 for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
Zti
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
7 A( <-U -7-Z issued on 0.5--/g _ iLexpiring on O 2. _ZDfi . 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 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 provisionNof Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant,_ jk _,-" Date 9-- /3.,/5—
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and swopto before me by, -oc_,; t, S+� (xc�Kn,,,� on this �,i day of
ilfi
A _ �.� T
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).
f
l r
Signatututeorf Polios C ief 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.
Signature of City Clerk or designee
Office Use Only
5-13-11"
Date
Clerk,TAXIDRIVBADGEAPPL92014amended.DOC 02/2015
0
Approved application
:3E2
3
a
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DCI report
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State certified driving record
Website update
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Clerk,TAXIDRIVBADGEAPPL92014amended.DOC 02/2015
Iowa Department of Transportation
Ofte d Dagw Service* (TDII f ree) 800 532-1121
Pt? Sex 9244, Um Mattes, U4 503D6-9244 515-2449124
s 1 A%: 515 239 1831
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
4/30/2015
DL/ID #:
127AC8472(IA)
Customer #:
5231945
Name:
Laskowski, Joseph
Class:
D
ID Status:
None
Walter
Address:
836 WALNUT ST
Audit #:
5981226
DL Status:
VAL
Issue Date:
05/15/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
04/25/2017
CDL Cert Status:
None
522403340
Endorsements:
3
CDL Med Status:
None
Mailing Address:
836 WALNUT ST
Restrictions:
Corrective Lenses
Restriction
None
Supplement:
Date of Birth:
4/25/1973
Mailing
IOWA CITY, IA
Sex:
A
City/State:
522403340
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
09/13/2013
10/02/2013
S93
5 eed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date Case Number JUR
09/07/2012 703362 IA
09/13/2013 757141 IA
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
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:
4/30/2015
Office of Driver Services
Iowa Department of Transporation
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
Ao r. 311. 21015 1 1:25AM
04i[uizo15 IJ; 48 FAA
Div of Criminal lnve,ti W lon net Io1No,6239 F' 1TA �i
STATE OF IOWA
Criminal History Record. Check
Request Form
To: laws Division of Criminal Inveatlgatlou
Support Operations Bureau, V Floor
21$ L 10 Streat
Dm Molnea, Iowa 50319
(515) 7IF-6W
(516)?2&4080 Fal
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DCI Ac went Number _ 3g�
(irt*iubre)
Krum: MIX V e5TaXt
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Phone: ,c 3 t ) 33y-
--T 319 351
t am R uestin an Iowa crlminel rnsro
Last Name mamawryl
a =DM �11w& vii•
First Name mmdtlo >
Middle Name acumaeak4)
Date of Birth arad.w
Gender vanhm
Soclsi Securl Number r asd
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Owe ❑Female
^�lmm
S Z_372
Waiverinformarion., without a signed waiver Mom 'no sub�ecet�al bYf be mry recwrd otormatloo�ui� Mowed by 1 w a w Ysistory record mxy t
be releasable, per Code oriowa, Chapter 692,2. For complete
owlen allverlignaterettomthe bl4toftheregibelt.
Waiver Released arimhbygift RTM� tennfo(lbb ebovc m t�inog'of%,cill 1* ow"' rcicambull eredeahtlleWed by lecbak Nilh Ula DlublOn orCrirNarl
Invmliea{bn (MO AuY " K
Waiver signoras:
Iowa Criminal Ki to Record Check Results (ocrma tdY)
As of a search of the provided dame and date of birth revealed:
taf No Iowa Criminal History Record found with DC)
❑ Iowa Criminal History Record attached, DCT# , - r,,''.1
DCI initials r: Y
nrr_v9 l0A125/101
Received i'ifre Aor.99. 2015 1:42PM No, 6658