HomeMy WebLinkAbout15-1631 r ,
CITY OF IOWA CITY
410 East Washington Street
lona City. Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
IDENTIFICATION NO. ) La—�
(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
Middle
1. Name (REQUIRED) _}l- Munn �{sa CS Qebel{ems
2 Address (REQUIRED) 515 C nA
3. Contact Information (REQUIRED) Email: _�v�oe!/a{ Yo1 �tl M Cell Phone:
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 11
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted j Dismissed Deferred Suspended Plead Guilty Other
i
7. Have you been arrested Tckarged with any traffic offenses in the last five years? A%6)
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted 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? t/
Type of offense Where When
9. Havg you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the rgne(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA"
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE
You must apply for an individual Department of Criminal Investigation Report (form
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOT
R11W-W,U s
REVIEWI�—
upW req+JesR).
i"v 0
C+7
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
1 herebxx certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
K,1
3 n - ! , - �G>( issued on / expiring on 1(lt(10 . 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 Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Ikd o 1 _ e LS lt-e " on this I 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 t 1 / // l �� 1
Signature of Po i e 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.
wk,.
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
9//.3 1.20
� Date T u
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aerW MDRNBADGEAPPL92o14 ... asa.DOC 03/2015
08/12/2015 12:57PM FAX 3193397302 Z0001/0002
oeAug, 12. 20152-1_57PMCapOiv of Criminal Investigation (FAx)3193as2No. 2894 P., 1/6,0003
4?S TATE OF IOWACr.lrninal History Record Check
Request Form
Tal Iowa Dlvlaloa of Criminal Invostlyatlon
Support Operations Bureau, V Floor
21S It. 71" 8tras,
Des Moines, Iowa 50319
(515)725.6066
(525)'725-6080 Fax
DCI Account Number: 9967-P
�- (lrrppllorela)
From: Ye11ow Cab ofxowa Clty
8,4. Box 428
Iowa City, IA. 52244
(319) 338.9777
Phone:
pp%, (319)339.7302
(DCI ua onty)
As of / / a search of the provided name and data of birth revaidad:
r
ID
No Iowa Criminal Histo ryR000rd found with DCI
U-
Iowa Criminal History Record attached, DCI 0 7571
y U
•'' C,
C)
`
DCllnitials
^�
DCI.77 (08/25/10)
Received Time Aug. 11. 2015 9:26AM No -5126
08/12/2015 12:58PM FAX 5193397302
Aug.12. 2015 1:57PM N v of Criminal Investigation
IOWA CRIMINAL HISTORY
MISDEMEANOR CONVICTIONS ONLY
OCI:00757798
NAME- RBBBLSKEY, ADAM JAMES
DOE SEX RAC
19861111 M W
ADDITIONAL IDENTIFIERS
01 ARRESTED 20050S20
AGENCY: IA0060000
CHARGE NO- 01
DRUG PARA
TRK#: 074600901
COURT DISPOSITION
AGENCY: ZA006015J
COUNT NO- Ol
HOT WGT EYE HAIR
509 135 BLU BLN
CCH RECORD •••
88NTON CO SO
IA STATUTE IAX24-414
RENTON CO DIST COURT
IA STATUTEi IA124.414
DCI 00757798
PAGE 1 OF I
DATE PRINTED -
2015/08/12
SK" POB
IA
POSSESSION OF DRUG PARAPHERNALIA
COURT CAS$ ID: 06061 SMSM003534
CHARGE CLASS, MISDEMEANOR CONVICTION
TRK#: 074608902
SENTENCE DIBP EFF DAT
FINE $250 20051201
U0002/0002
No, 2894 P. 2/6
AN ARREST NITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THU IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION I$ A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW
SNFORCEMBNT AGENCIES BY THE DCT.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED. WS CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR XNOUIRY.
DIVISION OF CRIMINAL INVESTIGATXON
Iowa Department of Transportation
iLA F,,%X LMa.239 16M
01hr0 fir LIP,vef S"OrCS flrel 4 IOe) I." U U2 1 Q1
PQ BoX 9204, Cir, MuAnM'ILA 503M 92N 5i� e44-4tj4
Certified Abstract of Driving Record
Inquiry Date:
8/11/2015
DL/ID #:
432YY3012(IA)
Customer #:
4728613
Name:
Rebelskey, Adam
Class:
D
ID Status:
VAL
JUR
James
Suspended
Suspended, Denied,
12/04/2012
D51
Address:
515 PENN CT APT 8
Audit #:
9110672
DL Status:
VAL
Child Support
Issue Date:
05/26/2015
CDL Status:
None
City/State:
NORTH LIBERTY, IA
Expiration Date:
11/11/2015
CDL Cert Status:
None
523177303
Iowa Fine
Suspended
05/10/2012
Endorsements:
3
CDL Med Status:
None
Mailing Address:
515 PENN CT APT 8
Restrictions:
NONE
Restriction
None
Suspended
10/30/2012
Supplement:
D51
Non -Payment of
IA
Date of Birth:
11/11/1986
Mailing
NORTH LIBERTY, IA
Sex:
M
Suspended
03/05/2013
City/State:
523177303
Non -Payment of
IA
IA
History Information
Child Support
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
10/04/2010
10/20/2010
B20
Driving While
Polk
IA
JUR
Suspended
Suspended, Denied,
12/04/2012
D51
Non -Payment of
IA
IA
Cancelled Revoked
Sanctions
Type
Effective
End
ACD
Explanation
Occurrence
JUR
JUR
Suspended
09/22/2010
12/04/2012
D51
Non -Payment of
IA
IA
Child Support
Suspended
02/09/2011
02/10/2014
D53
Non -Payment of
IA
IA
Iowa Fine
Suspended
05/10/2012
05/13/2012
D51
Non -Payment of
IA
IA
Child Support
Suspended
10/30/2012
12/04/2012
D51
Non -Payment of
IA
IA
Child Support
Suspended
03/05/2013
08/25/2013
D51
Non -Payment of
IA
IA
Child Support
Suspended
06/06/2013
08/25/2013
D51
Non -Payment of
IA
IA
Child Support
Suspended
01/10/2014
03/05/2014
D51
Non -Payment of
IA
IA
Child Support
Suspended
01/10/2014
03/05/2014
D51
Non -Payment of
IA
IA
Child Su ort
o��r,P�nP�i
02/13/2015
05/19/2015
D51
Non-Pavment of
IA
IA
Suspended 02/13/2015 05/19/2015 D51 Non -Payment of IA IA
Child Support
Name: Rebelskey, Adam James DL/ID: 432YY3012
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:
8/11/2015
IOWA
L1.0 T
Office of Driver Services
Iowa Department of Transporation
Name: Rebelskey, Adam James MAD: 432YY3012