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Home My WebLink About15-283r 1 `IIIA cccccrz io CITY OF IOWA CITY 410 East Washington Strccl Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. /5— Z9� (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 First LKS Ul5 3. Contact Information (REQUIRED) Middle Last til V'L(5-r- St. CIS..,.„,,, .e((�>' Email: S e � d I € e e.—.;( yCell Phone: (All written communication sent Va email) 4a. Chauffeur's License expiration date (REQUIRED) _ b. Taxicab Business Name (REQUIRED) _ L tx 5. Prior experience in transportation of passengers: 5 17/ z2 -- I ; IS (4J )-4,Y, 373 acv ��2 V 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense ` Where When �Y'wC-f! '1'-t� �t W(c7 t��`ci Sl c,cl lc7 �n•s v��['d t.. 'ly 'z C7lu 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 4 5 ^ Tint yn ),stn„5„„ (a_..,l,/ 2ON) Zoll ypr[r( 'Tu c"_s0 t U ” '2 CUlZ)2oll 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? H 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 pro vide the n-ame(s) L -ti W l(cN DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE'CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE QHIJ�f REVIEW—, You must apply for an individual Department of Criminal Investigation Report (form available upW requesi). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)s 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I herebycertify0 that I haq(d Cj?d to me by the Iowa Department of Transportation a valid Chauffeur's license number lI (( >> issued on 2_141 S expiring on 7 ! I/2L . 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 the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by �_Sal��ti� , )„ p jL.::k on this l i day of r _ , d� WENDY S. MAYER4 28 My Commission Expires row _7_)1_) 10 Public in dC�d for the State 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 off?Chauffeur's license /l( ?/? JZ -L Signature of P I 6-ChW 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 Date 11 c - Office Use Only ? ^" on x� ° Approved application DCI report -77 State certified driving record Ln Website update ciertnanioRiveaocE PPrs2014.m.�ded ooc 0312015 Viv 01-1,r'mIORI lnv srl �'dtic,n vU. --- 11/12/2016 STATE OF ROWA ` ➢1 ial�fl Hitt ry Record Check �J Request Form � DCPAcccuntPJmnber: ��-'�__ 074Plichlc) -• "i o; Rasa lbivlsion of Cl�imblal Pnvestiyetinn 6upporf >SperetioltY f3ureav, l" 1�foer F1 wit: City of Iowa Cid .-__-- 215 L, 70' Street Ci y Clerh's C1fSct f)co Moines, town 50318 `il0 G _Washin tun �treef — 1^ r.tS Fk s22 tB (315) 725-6000 Fa>i anil'equcsttnp nll oil: Phone: 319-356-5641 rax; 319.356-5497'�� (nuud al!-f 1thGEndEYsOC1 Security rN,U111Cra 1�(reeontnnutdr I k 6 U__ Male ❑Femaled 6 t S U T3`alvE!'InfOrPltrlri W, 1N41.10. a signed waiver from the subject of the request,a complete erbd,141 history recoi d may not be releasabie,per Code of Town, Chapter (92.2, For corn tete Crinlival history record information, as allowed by taw, always obtain a waiver si,rnatm a frwn the subiect of the 1'ennerf. Iilvc; .g o I ( C _ ._- _.. ... ,..- l a'J" "'6 mnem m cunni¢[ tm Iowa criminsTTj51w}'ttt'01' C cc x111 [ IC Wsinn Of�rmnuT— ti ati t ❑ 1)..any rriinhtal hirdop•daln cnncwtiug me d'eal is maiwaintdlyvthe,bcv- rc -Q s5t aS allowed 6y lain. W(IhJerSign toture: 10110 Crinlinal Histo r / Record Check Results frt/ As of t � a search of the provided nan)G and date of birth revaalc& cw) No lova Criminal History Record fouuci with DC1 ❑ iowa Crimiltal Histury Record attached, DC # - DC1 initUs DCI -77 M/25n o) - — — — -- �— — -- -- ----a : — — —1 Re( eived Time Nlov,12. H 15 2:25PM N 1905 4�4�WVVADOT Office of Driver Services PO Box 9204 i Des Moines, IA 503C.,6-9204 Rhone: 595-244-&124 1800-532-1121 ( Fax 515-239-1837 www.ivwadot.gov Inquiry Date: 11/12/2015 Customer #: 1827411 Name: Willberg, Lee Marinus Certified Abstract of Driving Record DL/ID #: 760YY4065 (IA) Class: B Audit #: 9360690 Address: 1115 SAINT CLEMENTS ST Issue Date: 08/21/2015 Expiration Date: 07/17/2022 City/State: IOWA CITY, IA 522456111 Endorsements: NONE Mailing 1115 SAINT CLEMENTS ST Restrictions: NONE Address: Restriction None Mailing IOWA CITY, IA 522456111 Supplement: City/State: Date of Birth: 7/17/1980 Sex: M CDL Medical Examiner's Certificate CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: Ernest COL Permit None Endorsements: Perea COL Permit None Restrictions: 3244024129 ID Status: EXP DL Status: VAL CDL Status: VAL CDL Permit Status: ELG CDL Cert Status: Non -Excepted Interstate CDL Med Status: Certified Cerflfxcote sp"L'CMCs Explanations '.. Medical Examiner First Name Ernest Medical Examiner Middle Name Manuel Medical Examiner Last Name Perea Medical Examiner License Number 330791. Medical Examiner National Registry Number 3244024129 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 339-3921 _ Medical Examiner Type Medical Doctor Medical Certificate Issued Date 07/10/2015 Medical Certificate Expiration Date 07/10/2017 j Date Added to CDLIS Driving Record 08/21/2015 History Information Convictions Citation f9alL,i Conviction Oa;<. ACD kapian�ition - ` ountE.. 3Uq 04/07/2011 04/07/2011 592 .Speed _.- _.lohnsot , IA 07/14/2012 07/25/2012 592 Speed �^^ ... Cgohns6n^��3 IA 08/04/2012 09/05/2012 M14 :Fail to Obey Traffic Sign/Signal ...<. X�Ioh ndnt i IA 02/12/2014 03/12/2014 M14 fail to Obey Traffic Sign/Signal - .,;-]ohnsolt-'i IA Name: Willberg, Lee Marinus Dli 760YY4065 Cl1 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: Willberg, Lee Marinus Dli 760YY4065 :.....!`/��y 11/12/2015 IOWA *'' �a r'••••• Office of Driver Services Iowa Department of Transportation w �a C� 77 4'1 Ce%