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Home My WebLink About15-257ul%711P ]L CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. m (Office Use Only) IS-,;�57 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" infarrnatlon wilt result in denial of theap 1p icatian First J0 3. Contact Information (REQUIRED) Email: i0 j A- RT e- M )lyijij�.LahCell Phone: (All written comm— unic� nt via email) 4a- Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) Y eljow 5. Prior experience in transportation of passengers: lid �etk 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 Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When What happened to the charge? (Circle one) 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? do Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro4.id=e theg me(s) n y A[. DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE TIF'f@D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C�F;RE4yEW You must apply for an individual Department of Criminal Investigation Report (form availably updWrequestj. 0 (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) — 0212015 i* APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I here certify that have issued to me by the Iowa Dep rt ent of Transportation a ali Chauffeur's license number rf � Z �f L/ 3 a issued on d Diol � expiring on I understand that if I falsely answer any questions in this application, that this a plic tion may be denied. I a re tat 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 O S STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by -To r K . 1+c, lLn on this M day of �a�rsI WENDY S. MAYER N rJ M mitis ion I res �+.5 — lows' Notary Public in anNff or the State of low i ***********************************************Xx XkX#XX*#X*##X#FXkkrtxxxxxxxxxxxxxxxxxxxxxxxxxxxx..Hxxxxxxxxxxxxx x xxx xxxxxxxxxx x xxxxxx xxx 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 `l l 1 F o— Signat o o ice Chief or designee I�hr 1015 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. /�� 9 l� /� Signature f City Clerk or designee - ate C9er~DRIv6ADG6 PPL92014 mandedooD 0312015 N rJ 'mi Office Use Only c, i Approved application -` DCI report State certified driving record Website update CD C9er~DRIv6ADG6 PPL92014 mandedooD 0312015 ,01owa Department of Transportation Office d Dom Sefvie�s Boit ffeci - 2'9;24 24 po 9W 87034, Gies FAdnes, iA 503tl692f 4 515.23911837 FAx �~a�z�y�� Certified Abstract of Driving Record Inquiry Date: 10/12/2015 DL/ID #: 433ZZ4432(IA) Customer #: 3712754 Name: Hake, Jon Kenneth Class: A ID Status: None Address: 145 N DUBUQUE 5T Audit #: 7063375 DL Status: VAL Issue Date: 06/22/2013 CDL Status: VAL City/State: NORTHLIBERTY, IA Expiration Date: 04/07/2018 CDL Cert Status: Excepted Interstate 211 Endorsements: LNPT CDL Med Status: None Mailing Address: 145 N DUBUQUE ST Restrictions: NoCorrective Cl ss A and B SupplemRestrictent: ent: on None Passenger Vehicle Date of Birth: 4/7/1959 Mailing NORTH LIBERTY, IA Sex: M City/State: 523179211 History Information CLEAR DRIVING RECORD Name: Hake, Jon Kenneth DL/ID: 433ZZ4432 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: Name: Hake, Jon Kenneth DL/ID: 433ZZ4432 tl'7 10/12/2015 41 Office of Driver Services Iowa.Department of Transporation ren 4J L] STATE OF IONVA Criminal liis(oI»y Recol'ci Check 0 Request Form DCI Acctlpm Mini bet:__r..-•-- (ifapplicablc) To+ Iowa Division. of C:rilninal Iowa; ligalfun hronl; _ City of lnwu (:i y Iiupf ovi Opel a(ionx liur'eau, V Ftoar City Clerk's office 715 b:, 7a' Street 410 k, Washln Ion Street Des Moines, Jn,aa 50319 derideer/�(mandatory) 725-6066 _ TafitY tat 53d4_--'--,---'-_-,--- »N —^-- (5JS)725400 Fax (/8 -2 )6 S—/I2 Waiver rnf0rniah011. Wi(hout a signed waiver from the subject of the request, a complete criminal history record may not Phoile, 319-356.5041 Fax; 1 � .cii..� �. Irov.. (" not Uldmv krr•.nrrl f`hrrk nn• Last Name (maadetop) F1Pst Name (mandatary)___ Middle Naloe (recemmm�dcd) HA KP'— �ati � ��'t-1 l Date of Bil'th (rnandalap) derideer/�(mandatory) Sociai Seem -it}• Number (roecmmendcd) L2! )I5-9 _. MI2Ie ®Female (/8 -2 )6 S—/I2 Waiver rnf0rniah011. Wi(hout a signed waiver from the subject of the request, a complete criminal history record may not be rel easalfle, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by Jaw, always obtain a walvel'sIgnalurefrom fit esubject of Lite req uesit W(f!V ¢Y ,Rele(is¢: I hereby give permission for flit above requesting official to conddcl an Iowa criminal history mcord :)ock with the Division of Criminal bweu6garion(DCl). Any criminal hislop• data conccining Tne flat ismainained byihe➢Clmay be releasedas allowed bylave Wflive0'��fp Iowa Criminal History Recoi-d Check. Results tort t,>c only, As of __—��j //�/�J�J a search of the provided name and dale of bill h rovey)ed;'.. f f — ---- No lulva Crimi)ud 1'lislory Rccurd found with jJC;I }:t y r jnwa C'riroinal History Reeurd attached, /JCI fl____..,,-- C-"'. 1)C`1 n))Uals- DCI -77 (08/25/10) Recelveo Time Oct,13 2015 10;25W Ro,0044 d 109R'ONu91jBa°Ijs3Auj �ruiwil'j to nip Wd00 11 CIV,, '7!'1)0