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Home My WebLink About16-008CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 119) 356-5497 FAX IDENTIFICATION NO. j (p - C) T(Office Use Only) APPLICATION FOR TAXICAB I MOTORIZED PEDICA13 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 1. Name (REQUIRED) Middle L+r nos 2. Address (REQUIRED) I I 1 I ii rL A, [ Je il. i A g23 5G ?0 y3,,, 11-f 3. Contact information (REQUIRED) Email S.{r, { gdor,q(� ,tea., - y� Cell Phone: -3 n.32s-S2ti9 (All written com n ration sent via email) 42. Chauffeur's License expiration date (REQUIRED) ey b. Taxicab Business Name (REQUIRED) _ Yz I tura (A Ia 5. Prior experience in transportation of passengers: ?r, 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Nn Type of offense Where When lvl/4 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? &Jo 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? _ 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 r44a_rri' "" DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE`dl�RTIFISD DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVjEW .m.f You must apply for an individual Department of Criminal Investigation Report (form available upofr request). (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 s"SSXxm3css issued on lo ,b- <: expiring on S-zy.« 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 ),w G aNs Date a. -IS -i6 STATE OF IOWA ) COUNTY OF JOHNSON ) (� p cribed and sworn to before me by r ' I i C.t a-e—� �C�iI�� CLuiSf on this day of .:.%:i -- FLi�E iE v_I ary Public in and for the State of Iowa ssi n Ex fires 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 S/�YI 7, J/ 1 /rs l2,:j SignaturPdrice Chief or designee 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. S' not re of City Clerk or designee`✓ Date 0 Office Use Only cnn Approved application DCI report State certified driving record -, Website update ciennv IDRivenoGEAPPrs2maame,ded.Doc 03/2015 1 LL'IU II. LLMIYI UIv UI UI IIII 111dI IPV eII d, I, 1011 'n // � I. �. �� q Fro..,,`..> „� ,v wa �„,y park vinco :11b .'JGG 66®� Ol/oG/a016 13:36 / &2G2 P-002/002 STATE OF IOWA Criminal History Record Check � Request Form 11 �� DCIAcrountNwi)bei: TUO [if�polieable) To: lows Divisiwl of Criminal blVes(IIOis From! City of lows City _ StlppOrt Operations .liurcau, 151 I`'loolCify ClerlfS Offce Des Mottles, es, Iowa .50319 $, street 410 C. Washington Street Des ----- (515) 725-6066 lu"a City, 1A 52240 (515)72,5-60a0 rax Yhonc: 319-356.5041 Pax: 319-356-5497 omale.LI etnale Waiver Inforfl2ati01t: N'ilhout a signed Waiver tI Che subject of the request, a complete ❑iminal history record may not be releasable, per Code oflowa, Chapter 692.2, For comolete criminal history record infer mation, as allowed by law, always Obtain a lvaiver SlYnature from Lhe .cuhiere nrrhn .e..,...... WaiVCP Release; 1 hemap give pennia7i0n for [Ile ohm¢ regooi iogofiiciol to Wilduet en 1010 cr1111111aI8iSWry record check 1ri1411ea Division 0(Cf1111ina1 Invettigalion (DCI). MY criminol history data cmlceming me Ilial is mainiaiaed by IhG DCl may be rcicesed m allowed by law, Waiver Signature: P/ o4v/ 4 4 -- i -- Iowa Criminal History Record Check Results (DCI rt„!aaly) As of l 1 �o a search of the provided name e))d date of birth revealed: No Iowa Criminal History Record found with DCX Iowa Criminal Histor)' Record attached, DCI DCT il)itials ^'L. r.,t DCI -77 (08/25/10) Received Time Jan. 8. 2016 12:23PM No -503) 1UWA00T SMARTER I SIMPLER I ClDRIVE I WiPJtiN.iflWclC�Dt.(�QV a Office of Driver Services PO Dor'9204 1 Des Moines, FA 50306-9204 Phone_ 515-244-9124 ! 800-532-1121 1 Fa : 515-239-1637 vi r w.iawaeol.gor Inquiry Date: 1/8/2016 Customer #; 1906138 Name: Fankhauser, Michael Lee Address: 1111 8TH AVE City/State: WELLMAN, ]A 523569276 Mailing PO BOX 543 Address: None Mailing WELLMAN, IA 523560543 City/State: None Date of Birth: 5/24/1975 Sex: M CDL Medical Examiner's Certificate Certificate Specifics Medical Examiner First Name Medal Examiner Last Name Medical Examiner License Number _ Medical Examiner Natienal Registry NumberT.---- Medlcal Examiner lursdiction Medical Examiner Phone Medical Examiner Type Medical Certificate Restriction Medical Certificate Issued Date Medical Certificate Expiration Date Date Added to CDLIS Driving Record Certified Abstract of Driving Record DL/ID #: 555XX6308(IA) Class: A Audit #: 8544932 Issue Date: 10/18/2014 Expiration Date: 05/24/2016 Endorsements: LN Restrictions: Corrective Lenses Restriction None Supplement: Name: Fankhauser, Michael Lee DL/ID: 555XX6308 CDL Permit Class: None CDL Permit Issue Date: None CDL Permit Expiration None Date: io ..... 4 QIOWA°y CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: VAL CDL Permit Status: ELG CDL Cert Status: Nan -Excepted Interstate CDL Med Status: Certified Explanations -MEGAN BRZEZINSID. 5339033 - --- 9217063795 WI (920) 430 4593 'Physician Assistant lenses 09/21/2015 dive l _._.. Wearing mrre.._ .09/21/2015 09/21/2017 -09/28/2015 History Information CLEAR DRIVING RECORD 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 custodiar 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 b� authorized by the Director of the Iowa Department of Transportation to so Certify. :v In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Lei date: a� p�� io ..... 4 QIOWA°y 1/8/2016 D. 0. T..: � �+ �i4fOfQRIA Office of Driver Services , n Iowa Department of Transportatio Name: Fankhauser, Mlchael Lee DL/ID: 555XX6308