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HomeMy WebLinkAbout16-067r IDENTIFICATION NO. % U — o (Office Use Only) cmccrz APPLICATION FOR TAXICAB / MOTORIZED PEDICA13 VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m, to 3 p.m., Monday – Friday) 410 East Washington Strcet lova City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (3 19) 356-S497 FAX I. Name (REQUIRED) kk,.�rr11�'� 7 9) ast 12201 — 2. Address (REQUIRED) I "1 2 �� coo A s Zz C�� 3. Contact Information (REQUIRED) Email: (All written commune tion sent via email) 4a. Chauffeur's License expiration date (REQUIRED) 3/3 L 16 b. Taxicab Business Name (REQUIRED)_j� Ga.-C`j 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? What happened to the charge? (Circle one) Convicted Dismissed D(erre Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? vvnat nappeneo to the charge? (Circle one) Covi ed 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 9. Have y�u ver applied to be an Iowa City taxi driver using a different name? If yes, please provide the ame s' I r DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIFp DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW 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 h y c that ve iss ed to me by the Iowa Department of Transportation a valid Chauffeur's license number l �i (! � issued on j ZB^ l� expiring on t ��3 2 Z- . I understand that if I fats ly 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 relatingthis application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the rvjs(ons of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by �'. _,&; A, 7?—, l_1Lar-�,Z on this2 j day of tj Tn'ry SS. MAYER Notary Public in a for the State of Iowa htr GanMa 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). license 01-Z1.1 of Police -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. Sign re of City Clerk or designee Office Use Only lie ate r ra,7 Approved application u; DCI report State certified driving record Website update r. — co Clerk IDRIVHADGEAPPL52014amended.DOC J 0312015 Mai t 1. 2!11tl y:�4w Uiv OT t•riminal tnvestlgation No. 9911 P. 2/3 FrO rn:Cl[Y of IOWa G[y Clark OHlco 319 3666497 a3i15/2015 02[30 *436 P.002/002 STATE OF FOWA 0,11 Request Foam Ta lowa llivisiosl of CrimEual Tnvostigatlon support Operations Bureau, Ir' Floor 215 F. 716 Street Res Moincs, Iowa 50319 (515) 725-6066 (515)725-6080 Fax I alri reaueStinv an Iowa Criminal T-licinry Rnrni-81`1,nelr n— DCIAccawrtNunlber:_4_ OUB---�_— (irlit,U able) Frain: City of_lowa City -- City Cleric's Office 410 Y. Wcishiaglon Street Iowa Cid JA 52240 Phoac: 319-356-5041 Fax; 319-356.5497 Last LastNaute(mandnlory) FiYBCName Inandalo ry) li'filddleNome(remnlmended) 1 _= Date of 4i(0 (roan�� Gender (mamalory) Social Securi . Number (recmnlncndm) ID IJMaIe ❑lcmalc ��A'�l—(AI�� Waipeif Af0I'll 2arioer: Without a signed waiver frolni Cita sublact of /he M911 M, a complete criminal history record may not he releasable, per Code of Towa, Chapter 692.2. For complete criminal hWary record infm•malion, as allowed bylaw, always obtain a from the subject of the request Waiver, Release: IhereLpgironermi Intoy the eboverequcsltngofficial l4Condaeto111atvac6minalhisloryrcwrdeheckwith the bivlsimlorcriminal 11rValrolion (DCI). IVy uhn4isl history dal e if mine me that is mbiaiained by the DCl may b; released as allowed by lew, CYreiver 5'ignaler -�— ���- �•-� As of J I iO q senreh of the provided name and date of birth revealed. ❑ No Iowa Criminal History Record found with DCI C-,=<. 2-";. q t li>wa Crintitial History Record attached, DCI # �� l d•� DCT initials -_R -- DCI -77 (08/25/10) Received Time Mar.15, 2016 9,17AM No,9682 cr� (DFI aS&ouly) 1 _= C7 Co (5: Maf 21, 2016 9:34AM Div cf Criminal Invasfigah on No,9911 P, 3/3 DCI :00869032, NAME: NAZOAd,DUSTIN ROY DOB SEX RAC 19900123 M W ADDITIONAL IDENTIFIERS IOWA CRIMINAL HISTORY NON CONVICTION HGT WGT EYE HAIR 602 220 HAZ ERO CCH RECORD *** DCI 00869031 PAGE 1 OF 1 DATE PRINTED - 2016/03/21 SKN POE VT 01 ARRESTED 20090604 AGENCY: IA0570200 MARION PD CHARGE NO- 01 IA STATUTE IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE TRK#: SAD06ECOI COURT DISPOSITION AGENCY: IA057015J LINN CO DIST COURT COUNT NO- 01 IA STATUTE: IA124,401(5) POSSESSION OF A CONTROLLED SUBSTANCE COURT CASE ID: 06571 SRCROB3539 CHARDS CLASS: NON CONVICTION TRK#: 5AO06ECOI SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT DEFERRED JUDGEMENT lY 20090910 PROBATION ly 20090910 DISCHARGED FROM 20100311 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED By THE IOWA DIVISION OF CRIMINAL INVESTIGATXON, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF' CRIMINAL INVESTIGATION Ar_- 7J4iUVwAD0T ti- IVL WVV\V iow Bot g©�IU PRI Office of Driver Services PO 63a 9204 Des N;ulnes IA 5030v-9204 abone: ^15-244-41241 800-^_32-1+21 1 Fax515-239-1837 w'vrv. f ^'wado'..gov Certified Abstract of Driving Record Inquiry Date: 3/15/2016 DL/ID #: 134CC8201 (IA) CDL Permit Class: None Customer 4: 4544774 Class: D CDL Permit Issue None Speed (10 mph & under in 35-55 mph Date: Benton Name: Mazgaj, Dustin Roy Audit V: 8963357 COL Permit None under in 35-55 mph zone) Linn Expiration Date: 12/11/2008 Address: 1913 FLATIRON AVE Issue Date: 03/28/2015 CDL Permit None zone) Linn IA 07/28/2009 Endorsements: S92 Speed (10 mph & Expiration Date: 01/23/2022 CDL Permit None IA 06/26/2011 07/19/2011 S92 Restrictions: (10 mph & City/State: IOWA CITY, IA 522405961 Endorsements: 3 ID Status: None Mailing 1913 FLATIRON AVE Restrictions: NONE DL Status: VAL Address: Iowa Restriction None CDL Status: None Mailing IOWA CITY, ]A 522405961 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 1/23/1990 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County 3UR 07/18/2008 08/27/2008 S92 Speed (10 mph & under in 35-55 mph zone) Benton IA 10/08/2008 10/24/2008 592 Speed (10 mph & under in 35-55 mph zone) Linn IA 12/11/2008 12/30/2008 S92 Speed (10 mph & under in 35-55 mph zone) Linn IA 07/28/2009 08/24/2009 S92 Speed (10 mph & under in 35-55 mph zone) Linn IA 06/26/2011 07/19/2011 S92 Speed (10 mph & under in 35-55 mph zone) Washington IA 02/06/2013 03/18/2013 S92 Speed (10 mph & under in 35-55 mph zone) Iowa IA Name: Mazgaj, Dustin Roy DL/ID: 134CC8201 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: r --a ��dr�] . 3/15/2016 ¢way C� t Iowa of Driver e Department tof i aP Transportation-,--'. e Name: Mazgaj, Dustin Ray DL/ID: 134CC8201