HomeMy WebLinkAbout15-154r ,
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO.
(Office lyse 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
First
1. Name (REQUIRED)
Middle
2. Address (REQUIRED) ?—f "JS
3 Contact Information (REQUIRED) Email: llt O (6`�7°i�w 1161JI' i/ / a✓I? Cell Phone: 51i-3,56 IZ—;)lo
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) ?)115
b. Taxicab Business Name (REQUIRED) _ALLLOck-' CAN A fS <--r (2rr,F
5. Prior experience in transportation of passengers: `/�Go a-) C A
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /JL
Type of offense Where When
What happened to the charge? (Circle one)
Q
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? �L• J
Type of offense Where WhPn
VVIldL nappenea to the charge? (Circle one)
Convicte Dismissed Deferred Suspended Plead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ R_1Q
Type 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-2me(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE MR`fIFlgD
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C it
t.t
You must apply for an individual Department of Criminal InvestigationReport (form availal7{e-porn.requeW
I r=
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) W
r11
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby ce tify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
43Z y`l5`70 Z sued on 15 rI expiring on o9/23)70f 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 provisions of Title 5, C ter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date ys
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by LAt�C on this Ll day of
A. _ -1 .., oz-
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). f f
Expiration date of Chauffeur's license (�� l2 Z 12 Qt
k_.) 0 LJ
Signature of olic 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.
Ag4�, ��y
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
�/K i5
Date
ClerkrrA%IDRIVDADGEAPPL92014amended. DOC 03/2015
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ClerkrrA%IDRIVDADGEAPPL92014amended. DOC 03/2015
Iowa Department of Transportation
IC8
p ofAcedilMW servilm (icU Fm*) ODD -532-1121
Po Boot 9204, OM MMM, L4 50 9204 515 244-9124
FAX 515-2-101831
Certified Abstract of Driving Record
Inquiry Date:
8/4/2015
DL/ID #:
Name:
Prymek, Donna
Class:
5453760
Marie
VAL
Address:
2175 KOUNTRY LN
Audit #:
09/23/2015
SE APT
None
3
CDL Med Status:
Issue Date:
City/State:
IOWA CIN, IA
Expiration Date:
522409302
9/23/1979
Endorsements:
Mailing Address:
2175 KOUNTRY LN
Restrictions:
SE APT
Date of Birth:
Mailing
IOWA CITY, IA
Sex:
City/State:
522409302
Convictions
432YY5707 (IA)
Customer #:
3875157
D
ID Status:
None
5453760
DL Status:
VAL
08/18/2011
CDL Status:
None
09/23/2015
CDL Cert Status:
None
3
CDL Med Status:
None
Corrective Lenses
Restriction
None
Supplement:
9/23/1979
F
History Information
Citation Date
Conviction Date
ACD
Ex lanation
Coun
]UR
06/04/2012
06/19/2012
1 N82
Im ro er Backing
]ohnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
JUR
D6 04 2012
688631
IA
Name: Prymek, Donna Marie DL/ID: 432YY5707
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:
8/4/2015
' IOWA J'
CV
{}. Q. T, a
Office of Driver Services
Iowa Department of Transporation
Name: Prymek, Donna Marie DL/ID: 432YY5707
M.P. 2015 3:50PM Div of
07/24/201,61.07 AN FAX 3103397302
o7/,Jul. 24. 24151-. 9;0 IA. MGD i v o f
Criminal Investigation
Criminal Investigation
OF IOWA Criminal HistoryRecord
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