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Home My WebLink About15-119CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 35 6-S040 (319) 356-5497 FAX 1 Name(i QVniI !l Cr) _ 2. Address (1l5CR'Ii4: U1ll1l,1,F 0 IDENTIFICATION NO. -/T- //2 (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) r,.rUuno /rr ir Pf, "(r,. ^rr.a irna,r' �r�d�e�pRL,ra�irrn�rird'Nr'av redfir'rr t1*dtr /l�/dha�.4up�gnPdr rlPraar L /r fi. P, r,e LC 400u '-T, �� r' 3 Contact Information (HF `QUIIF FID) Email: ore. Cell Phone: (All written communi tion sent via email) 4a. Chauffeur's License expiration date (RIE OU.DIIFfll:..i _ cofaq �1 5 b. Taxicab Business Name PiL.B U1lllHE D) 5. Prior experience in transportation of passengers: S A lSo :I A 5DD(In ;r,p t vv\o\Vit-c"S a a& f 7 +-2 AQ -x" .i t r"Cl Vac'rnvtS eveniS- 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? L e Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred When r? Suspended Plead Guilty 6xD iJof sLr-f 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When j;"WAmck1 0�6d Sa5oI- C'ov-nAlXTA What happened to the char PIP (Circle one) Convic 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 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please N)J DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR PC You must apply for an individual Department of Criminal Investigation Report (form (SECOND PAGE FOR REQUIRED SIGNATURE AND When name(s) cn on ry 0212015 1171 ''i 171111 1;j:VF I hereby certify that i have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number XX Q55'7, issued on 51c?q1Jj 51d91/jexpiring on t0/a8//5 . 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 provisio s of,1Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applican '' ; IL -1 1 Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by ALAL OIA u. Lep on this E3 tA4 day of 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). Expiration date of Chauffeur's license c3 1—Z5`2Otg ,4I1.S3 Signature o Poli e Chief or designee of t),96— 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. Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update &/-e-/S Date Clerl Ml DRIVBADGEAPPL92014amended.DOC 03/2015 C"3 -=fes t cs Clerl Ml DRIVBADGEAPPL92014amended.DOC 03/2015 N t �� 1. Q, , ffi 4 i i�g �: yip DOT / id1VX� 1Qc"��tC{ SMA TU I StV,F f i `i1 STt')%,l.r.� DSIkvFN' u � �uaouo office of Drivet Services Fc] box, 9::'04 De -s Haines, to %3irt-9204 Ptianf.- 1.15-243--$124 80iEr`32-1121 1 Fa-, 515-23C-1837 's.:vrw loW3dCt.9ov Certified Abstract of Driving Record Inquiry Date: 5/29/2015 DL/ID #: Name: Leech, Autumn Christine Class: Address: 2401 HIGHWAY 6 E APT Audit #: 04/29/2015 4006 Issue Date: City/State: IOWA CITY, IA 522406721 Expiration Date: NONE CDL Med Status: Endorsements: Mailing Address: 2401 HIGHWAY 6 E APT Restrictions: 4006 Date of Birth: Mailing City/State: IOWA CITY, IA 522406721 Sex: Convictions 582xx4552 (IA) Customer #: 4028803 C ID Status: EXP 9043354 OL Status: VAL 04/29/2015 CDL Status: None 01/25/2018 CDL Cert Status: None NONE CDL Med Status: None Corrective Lenses Restriction None Supplement: 1/25/1987 F History Information Citation Date Conviction Danz Act) Explanation.... County JUR _.. 01/20/2014 .592 .Speed .Jasper IA Sanctions Occurrence 1JR 30P. T yyo Ef?ecti20 End woo NIot Entitled _.. _ IA ran�Pilart -10/01/2006 02/21/2013 W00 Not Entitled to Issuance IA Name: Leech, Autumn Christine DL/ID: 582xx4552 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 tin 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 sal[ 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. .�... '^ Me 11r 5/29/2015 IOWA r4� i D. 0. T. �s8 !i _ • �:;s Office of Driver Services Iowa Department of Transportation Name: Leech, Autumn Christine DL/ID: 582xx4552 FrcJ un. 4, 2 D 15w 11134r1NIC1or,Dfv of Criminal investigation ae;rosr zPls 12!'11. o, 9 y t1.1 . I/Lrooz kveSTATEOF IOWA Request Form Criminal History Record Check �kr :or.�' t9"7gy/i Y Tw lovva Division of Criminal Investigation Support Operations Bureau, 191 floor 215 C. 7" Strecl Iles Moines, Iowa 50319 (515)725-6066 (51.5)925-6080 Fax 1 ant requestinE an Iowa Criminal Hislory Record Chcek on; DCI AceountNunlber: qp - F .—t)(if appllcabla)--- From; Cit of Iowa City City Cleric's Office 410 C. Washington Sereet Iowa City, 1A 52240 Phone; 319-356-5041 Fax: 319-356-5497 L Last Naine (ma»dmor)q hil•st Name (mandatory) Noddle Name (recoosreended) 4��G�- nu�wrnn CtiC,&V,Y+ f Date of Birth (mnndamry� Gender (maadatwy) SOei�ayl Security NutnUer frecommend<d) �� a5/194 � ❑N/ale C�entale 1��- �+-y5�9 Waiver Xnforniatiow wifhout a signed waiver from the subject of the request, a complete criminal history record may not he releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as ellowcd by law, always obtain A waiver signature from the subject of the request. Waiver .Release: I hereby give permission Poi Ilse above rcitowing off cid to cm,ducr an Iowa aiat incl history record check. ,villi the Division of Criminal Investigmiou (DCI), Any ain i»al history data conccn ew n,e dial isMai/maiped by the DCI may be released as allowed by law. WaiveeSignature: ( Ij Zi— `, DCA -77 (08/25/10) Received Time ,`bn, 3, 2015 12:10PNf No -9725 Iowa Criminal History Record Check Results (DO use only) As of a search of the provided name and dale of birth reveale '_' .� *. '� f No Iowa Criminal history Record found with DCI _... y .i a c•� ❑ Iowa Criminal History Record attached, DCI ii_ ; DCI iuifials r DCA -77 (08/25/10) Received Time ,`bn, 3, 2015 12:10PNf No -9725