HomeMy WebLinkAbout15-233+�OV®i®@
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. lJ — , 3-�
(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
j Z L4
3. Contact Information (REQUIRED) Email: Cell Phone: Z4 Z
(Al Qn comnon Z
sent via email)
4a. Chauffeur's License expiration date (REQUIRED) cD -L
,A
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
here
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Where When
�ii5or���l� ��✓yc�utc,k 71�t^Sa1 � k h,, O � � ZcoS
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Ciad Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? N-�
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? tVo
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)
r.�
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT GERTIVF-D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CxkitJEP RWIEW-z
You must apply for an individual Department of Criminal Investigation Report (form avaiP"Supam req st).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY.p< - r. rip
Q? D 02/2015
r Cn
F,2
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
4 Ll r. C4 2.1 issued on QI17 3j?uj expiring on O 3/aL/2D?-( 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 'y Date Q� Z4 /L� IIj
*#**#*************xx**xxkxxxxk-xk%kxk%xxx%xxxxxxxx%%xx-xx%xxkxkxxx%%xxxxxx*xkxk**x-k*x*xxx%WWxx*WW%WWWW%W %W.tWu;uW**'FWxW**W*+Wk*W*WWW**k..N#d*##******
STATE OF IOWA )
COUNTY OFJOHNSON )
to before me by N-) EV� on this 4- L) day of
ENDY S.YER
72'• - e s t ��
cion Number 729428
:anmisaon F.��.ve Notary u lic in an f r the State of lower
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 5LOVd"-2—j
Signaturof P lice Chief or designee
,qL2 0�12-c)5
Date
AFTERAPPROVAL 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.
Sign ttur�City Clerk or designee
Date
Office Use Only
Approved application
t
vs
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DCI report
ru
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State certified driving record
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Website update
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Clerk/rAXIDRN9ADGE PPL92014amended.DOC
0312015
Page 1 of 2
Inquiry
Date:
Customer
4:
Name;
Certified Abstract of Driving Record
9/23/2015 DL/ID R; 334UU5927(IA) CDL Permit Class: None
1798490 Class: D
Fominyen, Muyang Boni Audit *: 9445038
Address: 128 E BLOOMINGTON ST Issue Date: 09/23/2015
APT 1
Expiration 03/02/2021
Date:
City/State: IOWA CITY, IA Endorsements: 3
522456205
Mailing
128 E BLOOMINGTON ST Restrictions: NONE
F fi
APT I Restriction None
DOT
IOWA CITY, IA Supplement:
City/State:
522456205
Date of
3/2/1984
Birth:
VAL
Sex:
.a.�.v
Office Of Driver Services
Pry gn, 32"19 Des Moines 64 50306-9 C1
Pho - _15-
93-i124I"i 5? -!'211 Fu'.IE55-2R&t."a,7
1NJn" ro'r:IIeo:. g-"
Inquiry
Date:
Customer
4:
Name;
Certified Abstract of Driving Record
9/23/2015 DL/ID R; 334UU5927(IA) CDL Permit Class: None
1798490 Class: D
Fominyen, Muyang Boni Audit *: 9445038
Address: 128 E BLOOMINGTON ST Issue Date: 09/23/2015
APT 1
Expiration 03/02/2021
Date:
City/State: IOWA CITY, IA Endorsements: 3
History Information
Convictions
CDL Permit Issue None
Date:
CDL Permit
522456205
Mailing
128 E BLOOMINGTON ST Restrictions: NONE
Address:
APT I Restriction None
Mailing
IOWA CITY, IA Supplement:
City/State:
522456205
Date of
3/2/1984
Birth:
VAL
Sex:
F
History Information
Convictions
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
04/03/2007
CDL Permit
None
Restrictions:
IA
ID Status:
VAL
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
04/03/2007
CDL Cert Status:
None
CDL Med Status: None
Cit;atlar Daae.
Conviction Date
,CCD
Explanation
County
JUR
01/06/2007
04/03/2007
S92
Speed
Iowa
IA
Sanctions
T.'vLe Efface€ve End ACU Explanation Occurrence JUR JUR
Suspended 05/28/2007 11/03/2007 S92 Serious Violation IA IA
Name: Fominyen, Muyang Boni DL/ID: 334UU5927
Pursuant to Iowa Code §321.1to I, Kim Snook, Director of Office of Driver Services, Iowa Depar�ment cfriransportation, do
hereby certify that I the custodian of the records held by the Office of Driver Services, that this is.g �Vue aroaccurate°copy of
an official record currently In the custody of said office, and that I have been authorized by the Direct of the i�ra Depahkent of
Transportation to so certify. —ti
i ^n N
Ithis date: rl a n witness whereof, I have caused my signature and the seal of the Department to be set upon thls„�1a'CJment, at An My, Iowa
i
CD
CJI
.......... n
9/23/2015
005.L7zvIJ �iw, uI o1 UtlminaI lnves[ioallon No. 6Z94 F. /11
Fro m:Cl�y or lawn G1fY Glum 0lrlc c. '_'.19 3686697 08/21/201s 16;56 .225 v.UUa1002
("'f illillal flisfory Record Chests
Request Fonu
'f is le'" Divislun of (•l iminal Invealg2t.ion
Sup pori. Opera tions Bursa u, 1" plp ur
.qt reel
Des h4nines, Iowa 80319
(515)725006
(515) 725-60aq }tag
oil:
DC 1 Ac-(;ouw Numbti _ 4•0p —
Iif epplfcablt)
From: Ci 11f)haV2 CiOI —
Cily Clerk's t)ftcc ___..._...
410 E. Whsfilr lou $enol-_
luu-9 City- (A 52240
I'bune: 319-336.50G1 _
f'ax: 319-35G-5497------^`—
OM21C 1 rsmale
Waive? LafpYrnrtfloN: Without a signed wolver from the sublec( of the req uesl, a complete criminal history record may not
be releasable, per Code of loore, Chapter 692.2, Tor complete crlrninat hisior), Leeord mpletea criminal
ign, as allowed always
obtain a waiver signature from the subject of the rcouest.
Rll'ifver Refetuer i hereby give ptmiission fol doe abocc rc uesnn
InvesliWi0,% DCI . Ah [hmmal Lis S 60 1c al to co"Wel an Iowa t/ihlihal les'crylt0ald cluck mi161Le Owision of Crimim
( ) Y IDi)• da10 tOnetibih� me 11151 it m5il"A'"d by ille T)CI MAY he released 85 anm'ed by law,
.n
Waiversiglwh re,
Iowa Crifllinal F�istor��ecard Check Results_.._—�---_-
II11;1 VSc
w11)')
As of � a search
_ of the provided name and date of birth
revealed:
�J
ILII No lova Criminal llislor}' Record found rvillt !)Cl
]owd Criminal I isloq Record atlached, ll(I
DU initials,-_
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Received T i me AuP„ 21 2015 4 51 PM N1o•6169