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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. [D — (� L-1 1,
(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
1. Name (REQUIRED)
2. Address (REQUIRED) J5/ i
3. Contact Information (REQUIRED)
.yc� t+j/( 7 Vditde Cs' ell Phone:
(All w ttenf communication sent is email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ mo_vx
5. Prior experience in transportation of passengers: _
,3,c- f.to shace l`lq /I r ----
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
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? Mo
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? LUQ
Type of offense Where When
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4
9. Have *yohuu ever applied to be an Iowa City taxi driver using a different name? If yes, please pro-
rothe nme(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE ICERTIF
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF;'REW
You must apply for an individual Department of Criminal Investigation Report (form available upoayTequest).
r -
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
022015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I here K ce ti t at I have issued to me by the Iowa Depa m nt of Transportation a valid Chauffeur's license number
J(Q �b S issued on01 20 expiring on O 2 I understand that if I
falsely answer any questions in this application, that this application may be denied. I agree t at in making this application, I
consent to allow agents or employees of the City of lova 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 provis��of19le 5, C Ipterf, of the City Clode. (Needs to be signed in front of a Notary Public)
Signature ofApplicant� y It 4,y Date3/�7
STATE OF IOWA }
COUNTYOFJOHNSON )
Subscribed and sworn to before me by b- T.A9, 0 on this
1%i 0.T, 5. 7t 11` n
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 Chauff license
Inature of Police Chief or des nee `L
0rLI o�\2n1 °
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.
Slgnafbfe of City Clerk or designee
Dat
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G'S
#x#xx##xkxkxkxxkkxxx*v:#*#***xk-xxxxxxxxxxxxx*x*x**x-xxxxkxxxxxxxxxxxxxxxxxx#xxxxxxxxxxxxxxxxxxxxxxxxxxxxv:++xxxxxx"Fwwxxxxxxxv*"�:*xxxxxxxxxk
Office Use Only
Approved application ` _
-� 4.
DCI report _-
State certified driving record w
Website update
Clerk TAXIDRN9ADGEAPPL92074a,.dedDOC 0312015
C410WADOT
SMARTER ! SIMPLER IUS7UNs� GRf1a 4--
Inquiry
Date:
Customer
#:
Name:
Address:
Office of Driver Services.
PO Box 9204 I O:es Moines, I9 50306-5204
Phone. 595-244-9124{SGO-632-112t IFax_596-23ca-1837
www.iew2ootgov
Certified Abstract of Driving Record
3/1/2016 DL/ID #: 636MM7805 (IA) CDL Permit Class: None
1621790 Class: D
Lubaroff, Helene Marie Audit #: 7195672
1514 SPRUCE ST Issue Date: 08/01/2013
City/State: IOWA CITY, IA
522406030
Mailing 1514 SPRUCE ST
Address:
Mailing
City/State:
Date of
Birth:
Sex:
IOWA CITY, IA
522406030
2/3/1966
F
Expiration 02/03/2019
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ELG
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
Iowa Department of Transportation
CDL Permit
ELG
Status:
'.J
COL Cert Status:
None
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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: Lubaroff, Helene Marie DL/ID: 636MM7805
3/1/2016
ry
Office of Driver Services
Iowa Department of Transportation
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alnre6.17 2016, 2:51 FM
Div of Criminal Investigation Y DCI 101V oOJ617
STATE OF OF IOWA
Criminal History Record Check w
Request Form
Tot Iowa Dlvblon at Criminal JaVemptlos
Support operations n■ream, Y Floor
215 & r Street
Dee Molle; tows 50319
('t5-) 715-60M
(515) 725-6080 FRI
I am recaeatdna an Iowa Ceimlrtat Hirinry Record Check on:
UCI A count Number)_
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Prom, _ a"45 I AX{
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Fax:
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FlrstName t
MmdleName(,errftwndpo
L��,�I����
Date of Hirth „aaeem
Gender
Social 9ocarl Number eco
0Z/03 /( 16 (0
9MNIe Female
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Watverirtformation: Without a aligned witIver from We subird of the regaeR, ■ complete u1minal Ylrtary record may set
be relea..ble, per Cade of taws, Chapter 6912, For Ump)M criminal hiwory record Information, ar allowed by hw, always
obtain aWaiver sl stare from 00 subject 0111be nest.
0 yo'ewromamnnam�anhaq-16eexuWMMePlwieeotct�
IWaiver
onR(efbleaj-rc:lywm�wnmo
Ay
mi..dwdlooidia.
Waiver Signata►c: l
Twit rimilaal History Record CheckHaulte tai, ar,ayt
As of ",a scamh of Zito provided name end date of blah revealed:
No ]own Criminal History Record found with DCI
❑ Iowa Criminal history Record attached, DCI 0{ °
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ACI.77 (08125/10) tj
Received Time Fe6, 15. 2016 10:09AM Na. 7308