HomeMy WebLinkAbout15-196—, :— ®- 4
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319)356-5497 FAX
IDENTIFICATION NO. j j C? L:�
(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
1. Name (REQUIRED) ho +-
Last
2. Address (REQUIRED) \til-)- /J , SuY✓1 itfnci--1- 5 -Ca U,4J- -
3. Contact Information (REQUIRED) Email: I�UAV,� O 1.4�QaLtc� r�f�o�� L Cell Phone:�i: amici -1 %3S
(All written commun'rdation sent via email)
4a. Chauffeur's License expiration date (REQUIRED) II l3
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
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6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?✓�
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
3
Type of offense
Where
When
vvnat nappenea to the cnarge r (arae one)
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? 4/0
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 name(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAiiRfRIED 17.
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICEc. - HIEF REVIEV#*.
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You must apply for an individual Department of Criminal Investigation Report (form avIlagthle %on r pst).
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(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)'' ry
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C" 02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
� l � C{ AL1 ✓♦ O L/ issued on S expiring on 11 ' 317 1 understand that if I
falsely answer any questions in this application, that this applic tion 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 tymzk�,' 1/� Da
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this day of
WENDY S_MAYER I Notary Public irfjnd for the State of
1 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).
Expirati�i date ofC ur's I�nse 10(Lfl <
/ o12 /,
Police 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.
Signature of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
94. ,1.5
Date
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Office of Driver Services
PO Bol 9294 Des Moines IA 50306-9:04
Phore: 515-244-4124 1900-532-1 721 1 Far: 515-239-1837
•wwv;. o•a•adot_gov
Inquiry Date: 9/2/2015
Customer 4f: 5136461
Name: Miller, Kathleen Michelle
Certified Abstract of Driving Record
DL/ID tF: 949ZZ4404 (IA)
Class: D
Audit 9: 9389769
Address: 1012 N SUMMIT ST UNIT F Issue Date: 09/02/2015
Expiration Date: 11/13/2017
City/State:
IOWA CITY, IA 522455939
Endorsements: 3
Mailing
1012 N SUMMIT ST UNIT F
Restrictions: NONE
Address:
05/30/2014
Restriction None
Mailing
IOWA CITY, IA 522455939
Supplement:
City/State:
None
DL Status:
Date of Birth:
11/13/1989
None
Sex:
F
S92
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Explanation
CDL Permit
None
Endorsements:
05/30/2014
CDL Permit
None
Restrictions:
IA
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Citation Date
Conviction Date
ACD
Explanation
County
JUR
05/19/2014
05/30/2014
592
Speed
Washington
IA
09/14/2014
09/22/2014
S92
Speed
Washington
IA
06/03/2015
07/29/2015
S92
Speed
Johnson
IA
Name: Miller, Kathleen Michelle DL/ID: 949ZZ4404
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:
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9/2/2015
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Name: Miller, Kathleen Mlchelle DL/ID: 949ZZ4404
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Div of Criminal Inv estlgati0n No. 3205 P. I/8
a DCI IOWA 1pJ U U 2
STATE OF IOWA '
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Criminal History Record Check
Request Form
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Tat I&" Whim oturimWal lnreetl[rtfoo
Support Operatloaa Bureau, I" Floor
%1S L 7e street
Dae Mob". low■ !0319
(Flt!) T25.60a6
(515) 726.6080 Far
DCI Account Number:
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111. 5kwcr.e Dr.
,bone: (3l4 358 -
Fel:.. 91 R 351
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Last Name
First Name Middle Name
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Date of Birth .r.eaa
Gender Lnw4powSocYal Seeurl IVamber
Omale tar Male Ygi-67-s�
Waiver lrlforntalian: Without a et8nd waiver from the mbject of the rappel!, a complete trlmlaPl buttery record may bot
be rdeaeable, per Code of lows, Chapter 691.2 For mmsleta orimlaal bbdory record lorormadoa, as allowed bylaw, Phraya
abtala a waiver a cure (roan the subject of the eat
Waiver Rekwg: I baebyeaamuseak Aw0+ skiewp4w*4 of ww am"mal6aeaaaw ammrreraeteawxwml die WvbleaorClimied
Iarndlju4p pCrI Aw wWxW aumy" c4owningwU* b bWmbd W w rlClmry be Mawee r mowed Mlow
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WaiverSignataro
As of _�4 L!�. 1 a search of the provided namo and date of birth revealed:
PNo Iowa Criminal History Record found with DCT
❑ lowa Criminal History Record attached, DCI q�
DCI initlulsL.—�
Received Time Aug. 14. 205 12:29PM No -5564
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