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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. f—( p— L)C)at
(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 t nn,.a.li_ _
J. Contact Information (REQUIRED) Email:-,) eLo( vN L -,)a Oke E`i / e�Bell Phone:
(All written communication sen is email)
4a. Chauffeur's License expiration date (REQUIRED)4-1 '-2) '�6 �- )�
b. Taxicab Business Name (REQUIRED) G I r
5. Prior experience in transportation of passengers: n p� fS
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?j\ 0
Type of offense
8
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? A'u.) .
Type of offense
Where
When
Type of offense WhereR
When o
`i c'.
9. Have you ever applie�dj two /be an Iowa/ City taxi driver using a different name? If yes, please pronid f'tie n iie(s)
ILII �l /\r ;r:! -E3 y p
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIES
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that �I—have issue to me by the Iowa DepartmentQf Transportation a valid hauffeur's license number
�i �/ C•'P/ issued on f�j ,expiring on -� . 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 lliDate__1
STATE OF IOIMA )
COUNTY OF JOHNSON 1
Subscribed and sworn to before me by 4�I �L7�rxtic` on this (1 day of
.a a� WENDS. MAYER —LP, —e2 N
CA - commisslon Numoer 72s42a Notary Public incid for the StateIowa
commission E1
ow 2-11 Q r i
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
Signature 46e 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.
� -
Sign re cf City Clerk or desi nee
tll,5� /-4e��
ate
N
0
e
Office Use Only v <I.
- C,
Approved application
DCI report `v
State certified driving record M
Website update
ClerkrWIDRIVBADGE PP L92014amended.DOC 0312015
,Ja-n.-4. 2016_10:47AM�J.Dly of Criminal lnvestiga(ion Na 4489 F. 1/1
1Y /3l/�016 12:b, #36.
-
icer �.�.
STATE
T HistoryRecord `L.
�J
lowa Division ur'Criminal lnvesligaifon
Support Operations l3nrcau 1'" Floor
215 C. 71° Street
Des Moines, Iowa 50319
(515)'725-6066
(515)725-6000 Fax
DM Acommi Ncunber;
Wapplicable)
F"Cin: ClivofIOWaCif
City cleric's 6 fi 'c -~-
410410 CdVas6iri�[,on street
—1 -WA Clty, lA 52240
Phone: 319-356-5041
Paz: 319-356-5497
a search of the provided name and date of birth
No lova (7thninal History Record found with DCI
Iowa Criminal History Record attached, DCT #
DU i
))CI -77 (08/25,10)
Rice ived Time Dec, 31. 2015 11:48AM No, 4671
Jed:
rn
&
414iOWADOT
SMARTER I E'iPL R 1 EUS7Dh4LF [}RI4`E'1 WWtCil.lowadotgov
Office of Driver Services
PQ Dox 9204 ; Des Molnes,. lA 50306-9204
Phone: 515-244-9124 f840-532-1121 1 Faxi F15 -239A837
www.i iwadot.gov
Certified Abstract of Driving Record
Inquiry Date:
12/31/2015
DL/ID #:
413AF8068 (IA)
Customer #:
5597450
Class:
D
Name:
tool Besse' 1
Audit #:
9625325
Address:
431 5 SCOTT BLVD
Issue Date:
12/31/2015
Restrictions:
[IA
Expiration Date:
12/31/2020
City/State:
IOWA CITY, IA 522455526
Endorsements:
3
Mailing
431 S SCOTT BLVD
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA 522455526
Supplement:
City/State:
Date of Birth:
12/31/1985
Sex:
M
History Information
Convictions
CDL Permit Class:
None
CDL Permit Issue
None
Date:
)UR
CDL Permit Expiration
None
Date:
(Fail to Obey Traffic Sign/Signal
CDL Permit
None
Endorsements:
08/01/2013
CDL Permit
None
Restrictions:
[IA
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Citation Date
Conviction Date
ACD
Explanation
County
)UR
10/26/2011
11/28/2011
iM14
(Fail to Obey Traffic Sign/Signal
I1]ohnson
IIA
0]/13/2013
08/01/2013
592
ISd.
Pee
y5mtt
[IA
09/03/2014
10/30/2014
iN50
limproper Turn
Pohnson
IIA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation,
Accident Date
Case Number
7UR
10/31/20111654402
c=`
IA
08/03/2014
_
810536
IA
10/13/2014
....... ...1821545
_. IA
Name: Bodjona, Bassai ] DL/ID: 413AFS068
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certlfy 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 1 have
been authorized by the Director of the Iowa Department of Transportation to so certify.
N
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, lowf;(b is date',
c=`
�l0'`®: •. 1 12/31/2015
t a`
111148!
Gf1
OBIVE oaa Office of Driver Services
y
Iowa Department of Transportation