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Home My WebLink About16-010� r CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ IDENTIFICATION NO. ( 0 - n I p (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 Middle Last 2. Address (REQUIRED) /ySs /1/ J`206 3. Contact Information (REQUIRED) Email: rn,'�.kdi/u, �o /ior /t�sa yew Lia Cell Phone: Gam//' �/ �D—%3d J, (All written communication sent ia� email) 4a. Chauffeur's License expiration date (REQUIRED) Q "v1 V',5,?D/'j b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? NO Type of offense Where When 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? ogeed,7j Tvne of offense Where When What happened to the charge? (Circle one) Convicted) Dismissed Deferred Suspended Plead Guilty Other %} ,s <�,✓ Ce.Ec 8 Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /1/ , ? 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 orne(s),;,,_, ' 4� DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED ` DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF Ril IEW ' +l You must apply for an individual Department of Criminal Investigation Report (form available upon requei t). c� (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 & 5-m N 'L/ C, So issued on / A -3o-15-expiring on �;-2V —1-7. I understand that if I this falsely answer any questions in s 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:_Lzz&eAwyz z Date % JZj STATE OF IOWA COUNTY OF JOHNSON Subscribed and sworn to before me by ��l L )�op�}r,ru�this day of __f'_.- -I nr 1 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 2211(70/7 Signature of p f Chief or designee . Date AFTER AP OVAL 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 �e of City Clerk or desig e Approved application DCI report State certified driving record Website update A Date G1 Office Use Only _ , ❑erWr IDRI4BADGEAPPr52014amended.00C 03/2015 �WWADOT SMARTER I SIP PLEB 1 CfJSTCMER DRIVEN wAv.iowadot.gov Office of Driver Services PO Boz 9294 , Des monies, IA 503X 5'.04 Phone515-244-91241800-532-11211 Paa-515-239-1837 wwwiowadot gov Certified Abstract of Driving Record Inquiry Date: 12/30/2015 DL/ID N: 652AH4950 (IA) Customer #: 6044033 Class: C Name: Taylor-Woodfork, Michelle Audit #: 6524950 La Nora None DL Status: Address: 1455 N ]ONES BLVD APT 5 Issue Date: 12/07/2012 ELG Expiration Date: 05/24/2017 City/State: NORTH LIBERTY, IA Endorsements: NONE 523179026 Mailing 1455 N ]ONES BLVD APT 5 Restrictions: NONE Address: Restriction None Mailing NORTH LIBERTY, IA Supplement: City/State: 523179026 Date of Birth: 5/24/1974 Sex: F History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: CDL Permit None Restrictions: 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 IUR 37/20/2015 12/01/2015 S92 Speed Poweshiek IA Name: Taylor-Woodfork, Michelle La Nora DL/ID: 652AM4950 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: _ .FAltlf... h�4� IIRIE� �o �Uav�.o Name: Taylor-Woodfork, Michelle La Nora Ili 652AH4950 12/30/2015 Office of Driver Services - cr Iowa Department of Transportation -_ t_ O Jdn.IL. wio II;41NMI u l v of �,riminai Invesligalicn iuor. I PY✓, � �.Y Yr rUYr wru> GI6Yr. virwc ..rre .auu yr v♦ o7/'I t12o 7e i3:dc r3S% ,-, X103/003 ,lUr PySTATE OF IOWA Criminal Record r Reqtiest Form To: Iowa Division of criminal Investigation Support Operations Bu•eaD, I" Floor 215 C. 7'a Street Des Moinw, Iowa 50319 (515) 72.5-6066 (515) 725.6080 Fax I aIll feoneSthnO an Inwn Criminal Mictnru Rnnnrd rhonL n., )DCI Account Number: W cvo Z --F (ifapplicable) From: City of Iowa City City Cleric's Office 410 E. washh eton Stseel Jowa City, IA 52240 Phone; 319-356.5041 Fax: 319-356.5497 Last Name (mandato ) First Name Onandamry) nU ddle Name (/Uommended) 1hXIC,01, �r111�1'r, !• 4e.,Nm�aGr Date oi))ICtlq (mondatory) Gender mandatory) Social Security Number (recommended) ❑Male Memale 3.57-W q-q3S-3 Waiver AnIforntafiont without a signed walver from the subjeet of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a Waiver signature flran the subject of the request. Waiver Release: I hctoby give permission fol Iho above requesting official to conduct an Iowa wf Inioal history record cheek, with the Division of Criminal Inveslisalion (DCI). Any criminal hist nq data concerning me flim is'meimauted by the nCI may be «leased as allowed by law. Waive), Siguafure;,��q._. Iowa Criminal History Record Check Results (Dict n:< nly) As of 1, i 'A \ y a search of the provided came and date of birth revealed; No Iowa Criminal History Record found with DCT �a Iowa Criminal History Record attached, DCI #� t7, o DCI initials rJl�l-�t (ueiz5i)v) Received Time Jan. I1. 2016 12:31PM No -5126 �ani[Lulu II14rHWi uiv of �runinai i n v s s t I g a I i c n 110, 700 1 0 Fi._....—..� _. •��.� �..� Gbl �. .....-.� -.._ __--.—a. 01/11/2016 13:4— a3e37 r.p02/OD3 STATE OF IOWA Criminal Record Request ilayfQ r ' \ 3•b}�History 4 :r rm rt4.1��y To: Iowa Division of Criminal Investigation support Operations Bureau, 1" Flnor 215 C. 7" street Des MDIIIes, Iowa 50319 (615) 723-6066 (515) 725-600o Fax 1 am reau estinn nn Mum 6in,inaI Ni1.1--i nl....6 ,.... DCI Account Member: Qtapylicobk) From: Cil' of Lows Cit City Cterh's Office 410 E. Washington street Iowa City, 1'A 52240 Phone; 319-356-5041 Fax; 319-356-5497 LastNatne (mandatory) First Nftme (viandale,y) Middle Name Oewmounded /7 1Ll�y' �Ua'M�il�ik Gv �I C'I� G� , �a, �t%c IC LI. Date of Birth (nlandalory) Lender (manaaldry) Social, Securit ' Number (recommended) (U S —3 7 ❑l42ale atnale 3 S 7- 6, `/' Waiver Information: Witbout a signed araiver from (he subject of the request, a complete criminal history record may not be releasable, per Code of iorva, Chapter 692.2. For complete eviminal history record information, as allowed bylaw, ahvays obtain a waiver Si nature from the subject of the re uesY. T�/QlVef' Release! I heleby give penninion for Ile above requesling officialm condoclw lora criminal history record check with the DlYision of Criminal hrvcsligation (DCI). My criminal hfstory data conecrningmc Ilial is mainlah.cd by the DCI may be relcasedas allowed by law. TFaiverSignf1Ure: 7,� _ (J(l� •.��C ICC t� � Received Time Jan.11. 2016 12:31PMNllo-5126 Iowa Criminal Histor Recnvd Check Results ^` As of _ a search of the provided name and date of birth fevenled: f -•_ No Iowa Criminal 14istory Record found with DCT Iowa Criminal History Itecoid attached, DCI #_ DC1 initials__ s; rj DCI.77 (05/25/10)�� Received Time Jan.11. 2016 12:31PMNllo-5126