HomeMy WebLinkAbout15-244I r 1
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CITY OF IOWA CITY
410 East Wash]ngton Street
lowa city. Iowa 52 240-1 82 6
(3 191 356-5040
(319) 356-5497 FAX
1 Name (REQUIRED) _
2 Address (REQUIRED)
IDENTIFICATION NO.
(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
3, Contact Information (REQUIRED) Email:
4a. Chauffeur's License expiration date (REQUIRED)
communication sent via email)
-2.3 — Zozo
Celli
I , Taxicab Business Name (REQUIRED) 4 c L Lio tO CA -A bt= xt tv GX i i
5. Prior experience in transportation of passengers: 7 y EA 23 W LT H 011 ?)0 696
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? loo
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested 1 charged with any traffic offenses in the last five years?
Type of offense Where When
s isP tz am g.2 E3a f tL nc-'uG- e L,,/4/IM,
What happened to the charge? (Circle one)
<Convicted ,? Dismissed Deferred Suspended Plead Guilty Other � 9
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? +Vy
Type of offense
Where
When
� cn
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provi im name(s)
.-4 (-� �
DEPARTMENT OF CRIMINAL INVESTIGATION (DC!) REPORT AND STATE CIFI f
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CH}F'�F' EI/W
You must apply for an individual Department of Criminal Investigation Report (form available' upo'leques"tj
rn
(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
Ll32 `I 15 ? o -r issued on rf -if-IS expiring on q-13-70 . 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 provisjons of Title 5, Chapter.2 of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant_ - f)��z/ Date
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by e b kti 1 V r, It uA< tL on this L.e day of
0(t- ?old �_ 0. 1.IA _ . ,
sp1Ae
WENDY S. MAYER
,,��
My Commission Expires
iow'�'
for the State 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, Cityj Code).
Expiration date of Chauffeur's license G{/�
Signatur of 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.
Sig ature of City Cerk or designee — � Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Clej I MDRIVBADGE PPL62014amended.DOG 03/2015
1c,Oet, _-2. _ 2015:,_ 1: 35 PM, cab Civ of Crlm n a I Investigation No,7650 P. (FAX)319338'�i�� r1/1
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DCI A000unr Number: 9967-F
(Iropplloable)
Tot Iowa Dlvlslon of Criminal Investlgatlon From: Yellow Cab of Iowa Ci
ty
Support Qperatlons BuraAu, V Floor P.O. Box 428
2151;, T" Street
Dos Molnes, Iowa 50319 Iowa City, L4. 52244
(515) x5.6066
(515p725-608o-Ftj�- ... _ (31-9)-3'd�-9777 _.
Phone:
Faxl (31.9) 339-7302
Iowa Criminal History Record Check Results PC, a,, only)
As of 0 `Z1 t� a search of the provided name and date of birth revealed: r. 7.1
_. •,c� u
No Iowa Criminal History kocord found with DCT
❑
Iowa Criminal History Record attached, DCI'N �.• w;_.yy- - •m-..
DCI initials
hi
1)C1-77 (06125119)
Receiveo Time Oct. 1. 2015 11!1fAM No. 9315
G1
CIowa Department of Transportation
Office of Ofpref Seracm (Toll Free) -532.1121
PQ Box 9204, hes Mages, U4 5U3065G3�J244 b`15-244 9124
Fr'tlE_ 515 -?3J- i $3 f
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
10/6/2015
DL/ID #:
432YY5707(IA)
Customer #:
3875157
Name:
Prymek, Donna
Class:
D
ID Status:
None
this date:
Marie
Address:
2175 KOUNTRY LN
Audit #:
9434686
DL Status:
VAL
SE APT 1
Issue Date:
09/1.9/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
09/23/2020
CDL Cert Status:
None
522409302
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2175 KOUNTRY LN
Restrictions:
Corrective Lenses
Restriction
None
SE APT 1
Supplement:
Date of Hirth:
9/23/1979
Mailing
IOWA CITY, IA
Sex:
E
City/State:
522409302
History Information
Convictions
Citation Date
Conviction Date
ACD
Ex lanatic
Count
JUR
06/04/2012
06/19/2012
N82
Improper Backin
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
JUR
06/04/2012
1688631
IA
Name: Prymek, Donna Marie DL/ID: 432YY5707
Pursuant to Iowa Code §321.10, 1, 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 Dire¢pl of the�!'ewa Department
of Transportation to so certify. C"1
C=)
,
y
7
In witness whereof, I have caused my signature and the seal of the Department to be set upon thi5`dbEUnner
tl'�t
Aneny, Iowa
this date:
Cao
�yFilCiF"N�iir 10/6/2015
D. 0.
F
Office of Driver Services
Iowa Department of Transporation
Name: Prymek, Donna Marie DL/ID: 432YY5707