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Home My WebLink About16-034CITY OF IOWA CITY 410 Cast Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX t Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. l �,ef --(--) 9 (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 �r Contact Information (REQUIRED) Email: 5ti,Lyock- ) reclt,^7I"l 1co;ry) Cell Phone: (All-tvi-irten communic on sent via email) 4a. Chauffeur's License expiration date (REQUIREE b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: `i _)-0/ 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? ,i% Type of offense 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? /V 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? ✓ O Type of offense Where When y ------------ 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please pravi�,lhe A/C DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE <GERTIFr D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEVRE1i`lEW You must apply for an individual Department of Criminal Investigation Report (form available upon . request). r. (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 05 96�A-TaC-S issued on /-l9-[(„ 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 of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant t 12 I Date C� STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by < MAYER ... . _1) . . A on this L Z day of 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 Signatur�6f P,56e 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. SignNue of City Clerk ordesignee D e Website update ae&rAXJoameaoceAPaLe2niaemended.DOC 03/2015 Office Use Only ) Approved application+ DCI report State certified driving record Website update ae&rAXJoameaoceAPaLe2niaemended.DOC 03/2015 02.Feyb.19. 2016,c12,00PMCab of CrlnaI lnetlgation (Fnx)31s3s:oN7991 STATE ti 11 WA Criminal History Record Chec YE,7pr\iRequesi Form To: Iowa Divlslon ofCrlminal Investigation Support Qparptlons Bureau, I" Floor 215 8, 7" Street Doi Moines, Iowa 50319 (51S)125•6066 (514) 725-6090 Fax P. 4/43/003 DCI A600unt Number, ,9967-F f If nypllcabia) From: Yollow Cab ofIo'we. City RID. Box 428 Iowa City, IA. 52244 Phone: (319) 338-9777 Fax: (319) 339.7302 Date of Birth (mandate gender (mendalory 9oolal,Securl Number rosommcaded % %,) rrj Qlv81'lnJ0rma110p; Without a signed walror from the subject of the regpcst, a complgto criminal history record may not I1I boreleasable, per Coda of 4kvs, Chapter 692.2. For fele criminal hlstory�rocor4 Information, as allowed by lew, always obtain a Walver slpnature from the mhiare I r eh... ..... Y Waiver Release; I hereby give permission for the above requesting ofnelal to eandurd m Iowa cdminal hirlory raw.. check with Iha 171vidon orCriminol Inveadgarian(nCp. Any cdminal hluory data aenaamms mo that Is malnulned by tho DOImay be released AS allowed by law, ,A / • Waiver Signa[ure; +.�wuaa3 (DCI ase only) As of �t i a search of the provided name and date of birth revealed: 3 � i No Iowa Criminal History Record found with DCI } uc�_. ❑ Iowa Criminal History Record attached, DCI!! r DCI initials DCI -77 (08125110) Received Time Feb. 17. 2016 12;11PM No. 7596 Q010WADOT Rc'�p �",It)tit r dVL"ILVtiiV� L C� d tJt/ StAfFl k'ICU f.`F�I v' €Fl (iffier of Driver Services PO Bo� 92041 Des totes_ LA 54306-92L4 Phone S9a.244-912419011-5.3+ ^: t : Far: 515-239-1837 4 avv ,xrvadagov Certified Abstract of Driving Record Inquiry Date: 2/17/2016 DL/ID #: 059AA5965 (IA) Customer #: 937826 Class: A Name: Shryock, John Steven JR Audit #: 9719140 Address: 2378 310TH ST Issue Date: 01/19/2016 Expiration Date: 12/01/2019 City/State: NORTH ENGLISH, IA 523168588 Endorsements: LN Mailing 2378 310TH ST Restrictions: NONE Address: Restriction None Mailing NORTH ENGLISH, IA 523168588 Supplement: City/State: None Date of Birth: 12/1/1974 Sex: M CDL Medical Examiner's Certificate CDL Permit Class: None CDL Permit Issue Date: None CDL Permit Expiration None Date: Kurtz CDL Permit None Endorsements: 6568209668 CDL Permit None Restrictions: _IA _ (515) 265-1020 ID Status: None DL Status: VAL CDL Status: VAL CDL Permit Status ELG CDL Cert Status: Non -Excepted Interstate CDL Med Status: Certified ..=_r.i ai-S„r.'i`i Exp[a:cuticr..= _ Medical Examiner First Name Terrance Medical Examiner Middle Name _ Ora Medical Examiner Last Name Kurtz Medical Examiner License Number 01618 Medical Examiner National Registry Number 6568209668 Medical Examiner Jurisdiction _ _ N:......../4�y"1 Medical Examiner Phone ...... _IA _ (515) 265-1020 Medical Examiner Type Osteopathic Doctor Medical Certificate Restriction 1 'Wearing corrective lenses Medical Certificate Issued Date 01/18/2016 Medical Certificate Expiration Date 01/18/2018 Date Added to CDLIS Driving Record '01/22/2016 History Information CLEAR DRIVING RECORD Name: Shryock, John Steven JR DL/ID: 059AA5965 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. t> In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this ®ah2: _ —LI "71 t� eNk .... N:......../4�y"1 2/17/2016 PQ a: IOWA Z' „r D. 0. T 4s .......... ' Office of Driver Services e^� 4ph®fllA—`— Iowa Department of Transportation CI'1 ,. Name: Shryock, John Steven JR DL/ID: 059AA5965