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Home My WebLink About16-048r,r i -•...illi CITY OF IOWA CITY 410 Last Washington Street Iowa City, Iowa 52240-1826 (319) 356-5090 (319) 356-5497 FAX IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB 1 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) tj 2. Address (REQUIRED) H 76N le 5W Low c 3. Contact Information (REQUIRED) Email Cell Phone: �l 1 7381 G7 (( Ian communication sent tt7via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) _ YE I a �6 5. Prior experience in transportation of passengers: Om!/ V 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Ale2 Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where r 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? Alb b 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-name(sT Ain DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW - rr, 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 fy that I have issued to me by the Iowa Department of Transportation va d hauffeur's license number �� 4{k[ Q C, issued on �7,"15expiring on �/ I understand that if I falsely answer any question 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_ ' Dat 6P STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by on this —] day of Mee 6 c A. Zoll o Public in and for the State 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). J Expiration date of Chauffeur's license bdn-z J,4 I1(�z Signature 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. hC lt"eh'jc� _< - %vLaJ SignAture of City Clerk or designee Office Use Only 31-1 1z Date S'3 Approved application DCI report State certified driving record Website update CWWW] 03/2015 C4iUWA00T Inquiry Date: 3/4/2016 Customer #: 5145452 Name: Shaffer, Dustin Glenn Address: 4760 MAIER AVE SW City/State: IOWA CITY, IA 522408416 Mailing 4760 MAIER AVE SW Address: Mailing IOWA CITY, IA 522408416 City/State: Date of Birth: 2/8/1990 Sex: M Convictions Office of Driver Services PO Box 92041 Des Momes, IA 501306-9264 Phoi 51&24II-9124 i K&532 -l"21 i Fax: 1;15-239-1837 wwxv.iowad it.gov Certified Abstract of Driving Record DL/ID #: 961AA1261 (IA) CDL Permit Class: None Class: D CDL Permit Issue None 'B64 --No Insurance Card Date: '.IA Audit #: 8879985 CDL Permit None Johnson IA Expiration Date: Issue Date: 02/27/2015 CDL Permit None Endorsements: Expiration Date: 02/08/2018 CDL Permit None Restrictions: Endorsements: 3 ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None History Information atation Date Conviction Crate ACD Expiznafion County )UR 13/25/2014 04/25/2014 'B64 --No Insurance Card Johnson '.IA 13/16/2015 04/09/2015 °F04 Seat Belt Violation Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. accident Date Case Number JUR )4/0512012 .:680406 _ IA .... Name: Shaffer, Dustin Glenn DL/ID: 961AA1261 Pursuant to Iowa Code 4321.10, 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: Shaffer, Dustin Glenn DL/ID: 961AA1261 c� ....... ®/,��I 3/4/2016 ...,.. ' Office c of Driver Services Iowa Department of Transportation = ' Name: Shaffer, Dustin Glenn DL/ID: 961AA1261 02Mar. 1. 2016;-11:23 AMCob Div c Criminal Investigation(Fax)319336No 8717 P. 1002/002 STATIE OF IOWA Criminal History Record Check _S Request Form To: Iowa Aivl:(oa of Criminal invodOgpt(on Support Oparotfons Bureau, I" Moor 215 S, 7" Street Dw Moines, Iowa 5031P (515) 715.6066 (515)'725-6080 Fox or DCI Account Number:.9967-F OroppllaADle) Fromi Yellow Cab of Iowa Ci P,b, Box 429 Iowa Cit , fA: 52244 Phone: (319) 338-9777 Fexl (329) 339-7302 I v A16 �I+OInAIe / / WaIVeP Iafar/ryQfla; without f el1110d Walver from the subject of the rel(QOet, a complete criminal history record may not bo r in asabTe, per Code of Iowa, Chapter 6y2,2, For complete criminal htatory.raaoro Information, a9 allowed by laws aiµpys obtain a wnlver sl naiuro from the Subject ect ortho roeuast. Watber Release:l hereby give permission for the above inveslldellon(DCI). Myerlminalhistory data conaeminasn" Waiver to aonduat en lows adinlnAl hltloryteaord oaeall with the Divfsien ofCominal ��Y be raloaeed is allewod by jaw, As of �—I \o a search of the provided risme and date of birth roveeedt rem LU- No Iowa Criminal Pistory Record found with DCI ❑ Iowa Criminal History Record attached, DCI DCI initials__, DCl-77 (08123110) Received Time Feb. 29. 2016 9:24AM No, 8451 -- M _ (DCI We only) r ,:E ,z:_ C:—, C9 1'1 o'. F c,;