HomeMy WebLinkAbout15-263� r
CITY OF IOWA CITy
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(3 19) 356-5497 FAX
IDENTIFICATION NO. 2 (�
(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)
Fallure to complete the "re wired" information will result in denial of the application
1. Name (REQUIRED)
2. Address (REQUIRED) 1 S A
3. Contact Information (REQUIRED) Email:
4a. Chauffeur's License expiration date (REQ
b. Taxicab Business Name (REQUIRED) __
0
5. Prior experience in transportation of passengers_
Middle
Last
se I is e Cell Phone: -619 - T- 12 (�(�ti
communica ion sent via email)
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? �_
Tvna of nffenc.
Where
What happened to the charge? (Circle one)
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where
VVhan
I +o `G su�o)
What happened to the charge? (Circle one) �O in Y15u l Coun D) I S a0 I rJ 1
Convicted Dismissed Deferred Suspended lead Guilt Other„„ �
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? I� O
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 M9Gme(s)
b - r-.) c� i
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE GERTIFIfb o
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHfEV REVWW
You must apply for an individual Department of Criminal Investigation Report (form available upon deque'st}
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) cv
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Departmen of Transportation a valid Chauffeur's license number
9�/ X X 7ct -7.S issued on 0 expiring on O I understand that if I
falsely answer any questions in this application, that this appli ation may be denied. II tigneeaking 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 o, /
STATE OF IOWA )
COUNTY OF JOHNSON
Subscribed and sworn to before me by A _ )c. on this � da
c7 la r _� Y of
i:;;.� � Commsslon S_ MAYER
„�:° ` M Number 729g2g Notary Public in an for the State of to a
— Y C��mm�°rn Frniav
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).
license ( y ' Z / ( D
Chief or
fo127I�)'
D'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
Dat
Clea TAxIDRIVDADGE PpL92014amended. DOC
03/2015
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Clea TAxIDRIVDADGE PpL92014amended. DOC
03/2015
Iowa Department of Transportation
tJtti of Urhw Sefv1LC3 (100 E fee) f 111532 ,121
PO BOX £#2154. [Jf15 Masses, t+l 503%92134 515.244-9124
fA3t.. 515 2313 1831
Convictions
Citation Date
Certified Abstract of Driving Record
Inquiry Date:
10/26/2015
DL/ID #:
431XX7973(IA)
Customer #:
4283012
Name:
Kober, Tara Ashlee
Class:
D
ID Status:
None
Address:
4906 UTAH AVE SE
Audit #:
7292821
DL Status:
VAL
Iq
Issue Date:
08/29/2013
CDL Status:
None
City/State:
IOWA CITY, JA
522408322
Expiration Date:
10/12/2018
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Mailing Address:
4906 UTAH AVE SE
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
10/12/1985
Mailing
IOWA CITY, IA
Sex:
F
City/State:
522408322
History Information
Convictions
Citation Date
Conviction Date
on
JUR
09/20/2009
—
10/09/2009
ey Traffic
al
y Traffic
al
Coh
IA
12/11/2009
12/28/2009
:MCD:jlon
IA
Oi/15/2055
02/11/2015
Iq
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Name: Kober, Tara Ashlee OL/ID: 431XX7973
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of office of Driver Services, Iowa Department of Transportation, do
r
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a -true and aecurate copy of
an official record currently in the custody of said Office, and that I have been authorized b the a cr
Y Direc COr. gf'the I a DeClffrCr�ent
of Transportation to so certify.ro
+J yw�
In witness whereof, I have caused my signature and the seal of the Department to be set upon this kegl'ment,' Ankeh:µ#, jowa
this date:
IV
10/26/2015
IOWA
i
iii 1* Office of Driver Services
Iowa Department of Transporation
Name: Kober, Tara Ashlee DL/ID: 431XX7973
ria
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09/s e,9,-29._ 2015o 1,53PM Div of Criminal Investigation , DCI Iov, c. ]283
STATE OF IOWA 4
Criminal History Record Check ;
Request Form �.
DU A000uat Number.
,AA T ruenor�
To: Iowa WalonefMaInaltovartlgadea From ArYeS t 0.xl
Sapp" t)perstloaescrum,l"Floor 5}eaena Y•
215 L 1d Snwt
Ila Maim, loft 60319-
(515)-
(51-1972i6)80 Faateapot :319 338'
Pax,,• 31q SSI- a9`
L dmLLCMLI M MM w ""IN "M
Last Name
First Name
Middle Name
14--1d be
Trz�
A5b450
Date of Mirt
Gender fflu"
SocW Soead Tdamber
lI e
❑M.k OFemale
0- 68- 1Ga d,
Warr InfbrniaMn. Mhoar a alped wolvor from We nbtact of roe rn(reat, a comgtero erlmlod hlrwry remrd msy Bot
Chapter 692.1. For edmerat hlriorr rseotd lafbrmstroa, u aaowed by bw, olwmya
be ralnreMr, per Code of Iowa, l9WQhto
obaia a waiver Hare ftom o nab act of the r at.
Waiver Aeicase:r.aeayrsreoamrBsoero<wrwowwomdruonen+o�ain° �^e0mti'°'ercriaw
twmlyecaPM, AT by eebClmeybereiee w=4Mw.dbrlrw.
Wafver5ignatare: c ✓� �— Q
Xowa Criminal Hleto Record Check ults
As of. 1 �� (� , a twmch of the provided nsmc and date ofbirth welled; w; n
F `^ ' S
No larva Crlminat History Record found with DCI u� M
G7 Cn c
[�
low criminia History Record attached, DC1 b _
DCI initln,6 �
Received Time lep.26. 2015 4:24AM No. 8911