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Home My WebLink About15-166its CMECFh -^ia11r1ss CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1 82 6 (3 19) 356-5040 (3 19) 356-5497 FAX IDENTIFICATION NO..2,E t (2t 0 (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 of the application First Middle n Last 1. Name (REQUIRED) _ (f(/,CL(l�IA69Y/1 X//e7 C .� n 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email: ell Phone: 3/9 `38 3 ?41 A (All written communicatio sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b Taxicab Business Name (REQUIRED) _y. ] 10 W (r 5. Prior experience in transportation of passengers:. 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? &17_ Type of offense 91 What happened to the charge? (Circle one) Where Convicted Dismissed Deferred When Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A/p Type of offense Where 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please When the Wme(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE RTIFt5D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CFRE)(IEW You must apply for an individual Department of Criminal Investigation 9 � ' Report (form availalUp%requs . (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 !-� i q M/ LC/(O 19 R issued on jjZjLj ° ,i expiring on 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant ,w44:� Date q f S J 121 -EL STATE OF IOWA ) COUNTYOFJOHNSON ) Scribed and sworn to before me by 1 <-O�A llg 1 k n c --,-±I Rixon this day of T�� WENDY S. MAYER Notary public in andf r the State of Iowa 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 lI ` /h�; Signature o� ief or designee gZ46 Date AFTERAPPROVAL 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 ell ? Date L� cn Office Use Only a " Approved application DCI report � State certified driving record Website update n13 is ca CD cleNTAXDRN ADGEAPPL92DIaamended.00c 03/2015 Da,Aug, 12. 24154 1:58PMcat,Div of Criminal Investigation (rnx)stsssezNo.2894 �n�nvUnr4i. STATE , IOWA ��rWtl�,�111 ... Record ; r. , 3: Request:�1� To Yowa Dtvlalon or Criminal Investigatfon Support Oparartons Bureau, ]" Floor 215 E. 7" Street DO Moines, Iowa $0319 (515)725.6066 (515)'725.6080 Fax 6, VS�Male P. 6/621002 DCT Account Number; _9967-F (Ireeplle"bml From: 'Yellow Cab of inwa Clly P.O. Box 428 Towa City$ IA, 52244 (319) 338-9777 Phonal Far: (319) 339-7302 ❑Female a waiver WOr!llarlOp Without p Slgncd walvor from the Subleet ar tho reggest, a ¢oMplgto criminal history record may not bo r¢I¢aseblc, per Code of Yowa, Chapter 692,2, For m let crimlrlai history -record 1nCOrmatlon, es allowed bylaw, always eh(aln a lvalv¢r Si nature from the subject of the renunst. /' 01Ver R61Ca$e; 1 hcmby glva permla,ton for the ebo4d teq0eade8 olilclal tc conduct M lows ollmfntl history record oheok wish Iho Dlvlsion ot'Crlminol Invwtlgatloe (DCt), My orimleol hfnotr date tanceming me Ihat is malnfalncd by the bel may be relemed as allowed bylaw. Wal ver sig!raturel •/ Received Time Aug. 11. 2015 11 49M No. 5168 ... __.._ ,,,1.•.,.,,,, (DCI use only) As of / a search of the provided name and date of birth revealed; No Iowa Criminal History Record ,found with DCI ❑ Iowa Criminal History Record attached, DCI #� r; DCI initials='-, 'L' DC1.77 (09125/10) 1._. c.n Received Time Aug. 11. 2015 11 49M No. 5168 Iowa Department of Transportation C] I c: �t Urrver .r�n�es � iir111Frr }hl1fk`3� 1 A DC7 'BO0, :720;#, DM' M�onc—S, !A 503U01 D204 � W-91-'4 I 11A L,11:. History Information CLEAR DRIVING RECORD Name: Goleta, Wakweya DL/ID: 419WVV0198 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: 1 CDA Q. 0.T .A• Name: Goleta, Wakweya DL/ID: 419WW0198 8/11/2015 �y Office of Driver Services Iowa Department of Transporation Certified Abstract of Driving Record Inquiry Date: 8/11/2015 DL/ID #: 419WWO198 (IA) Customer #: 1645474 Name: Geleta, Wakweya Class: C ID Status: None Address: 2401 HIGHWAY 6 E Audit #: 7773313 DL Status: VAL APT 4435 Issue Date: 02/07/2014 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 08/08/2018 CDL Cert Status: None 522406701 Endorsements: NONE CDL Med Status: None Mailing Address: 2401 HIGHWAY 6 E Restrictions: Corrective Lenses Restriction None APT 4435 Supplement: Date of Birth: 8/8/1949 Mailing IOWA CITY, IA Sex: M City/State: 522406701 History Information CLEAR DRIVING RECORD Name: Goleta, Wakweya DL/ID: 419WVV0198 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: 1 CDA Q. 0.T .A• Name: Goleta, Wakweya DL/ID: 419WW0198 8/11/2015 �y Office of Driver Services Iowa Department of Transporation