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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. E-2-2-9
(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
G
r
3 Contact Information (REQUIRED) Email: �CIi{1C t/ico(c
(All written commu
Cell Phone:
sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 10 - a t —d-099
b. Taxicab Business Name (REQUIRED) /'lalrC O,S cc b j j C
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?
Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
When
Other
Where When
Convicted Dismissed Deferred Suspended Plead Guilty Other Qa'd
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
9. Have
Where
When
Ger applied to be an Iowa City taxi driver using a different name? If yes, please provide theX"ame(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
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
I h`QZr b c 1fify � have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
J �9) -<6 e Issued on 03-03 -kf&nXnlrinn on /0 .,?y -lo AP. I iindprctanri 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 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of ApplicantDate 05-
r
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ICe-, iy , t_otct_ on this 1 I day of
%AI]_,4
- wwLY�
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 1012 `ifZ2
Signature of Police Chief or designee
-*�Ar/>J-6
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.
Signature or designee designee D to
Office Use Only
Approved application C11
_
DCI report
State certified driving record
Website update
ClerkrrAXIDRNBADGEAPPr92014amended DOC 03/2015
004 20 9. 2016711_:42AM
Div of CYImIOaI InvestioatlaA DCI IOY...Na 3773 P. .�,I/1
' .,..
STATE OF IOWA
Criminal History Record Check
Request Form
Tot Iowa DlvWon of Criminal investigation
Support operations Bureau, 1" Floor
115 L 7" street
Am Moires, lows 50319
(915)71.1"066
(915) 735-6080 Fax
I am reanertina an lows, Criminal Histery Aeonrd Check nm
Iba t �„a1�
DO Account Number: X�I 1383 —Fc -
(if eypikalir)
From: AM05 �a•p1
lots, C,,. 4 . I A 5)J)4 o
Phone: ,(3A ) 338 -
Far:. 75-1-1 a51'
Leat Name owdenn)
1FIrstNome mendnmy)
Middle Name ,woaaneaded)
I a
K�I��
ISMO eP
Date of Birth awdaro
r-eoder InvnWa)
Soelal Security Number ,mammeadrd
/o -Ay l9 !
Mi ala ❑Female
y�b ' %. mo
WaiverIllformatfnn: wobout a dyed waiver ]tom the subject orlbo request, a complete erlminal h6tury record may not
be releasable, per Code of Iowa, Chapter 691.2. for complete criminal history record Information, as allowed by low, always
obtain a wstver afore from she sob ed otthe request
Waiver Release tn�rey`i+epetmlutonro�Nsabo» eq asrilyotiidairomdanenloveulmaulmuory owtddwcwAhdaolata,orcnm w1
TA'Mug ..PCA tilt aNneW bwwry dw OwArh it almw. b/� to mow U dlaxad q ILW.
Waiver Signature.,
Iowa lCriminol HistoEy Record Check alts(
DI ady)
As of 5 + ice+ a search of the provided name and date of birth revealed: r -:
No Iowa Criminal Histo Record found wlth.DCI �' 1
iT r,- _ ,�Q i
G r u, -
❑ Iowa Criminal History Record attached, DCI # o
0
DCl initials
Received Time May, 4. 2016 10:00AM NoA806
AP ZIU .. DOT
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VUR.ERI !Mr1"._IMTTM
Inquiry Date: 5/3/2016
Customer A: 5524372
Name: Nicola, Keith Christopher
Address: 804 BENTON DR APT 14
City/State: IOWA CITY, IA 522465204
Mailing 804 BENTON DR APT 14
Address:
Mailing IOWA CITY, IA 522465204
City/State:
Date of Birth: 10/24/1990
Sex: M
Convictions
Mice of Dnvef Services
RO ROX 9204 ; Des More, kA 50308-9204
'fhc'. a: 5?E344i372V (SDD-53'2-0421 ):o:� 5f5-in39-iP.:47
W'Aw Owadoico,
Certified Abstract of Driving Record
DL/ID M:
351AE3858 (IA)
CDL Permit Class:
None
Class:
D
CDL Permit Issue
None
B64
NO Insurance Card
Data:
IA
Audit V:
9975981
CDL Permit Expiration
None
.Benton
IA
Date:
Issue Date:
05/03/2016
CDL Permit
None
Endorsements:
Expiration Date:
10/24/2022
CDL Permit
None
Restrictions:
Endorsements:
3
ID Status:
None
Restrictions:
Corrective Lenses
DL Status:
VAL
Restriction
None
CDL Status:
None
Supplement:
CDL Permit Status:
ELG
CDL Cert Status:
None
CDL Med Status:
None
History Information
;Station Date
Conviction Date
ACD
Explanation
County
3llR
12/12/2012
03/26/2012
B64
NO Insurance Card
llnn
IA
.2/06/2015
'12/21/2015
'.592
;Speed
.Benton
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
eccident Date Case K.,.ber
.0/24/2014 .823456. JA.'..... ...... _
Sanctions
ype Effective End ACD Explanation Oct i"rence JUR I'JR
suspended '04/24/2013 06/23/2013 '653 Non -Payment of Iowa Fine SIA '.IA
Name: Nlcola, Keith Christopher DL/ID: 353AE3858
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 of rs, 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,^
ca
=�dsue yis d
3m10:'' .S6W 5/3/2016
IOWA %sia
°his41 _
11j ces
IoweDepartme t oof Driver f
Iowa transportation
Name: Nicola, Keith Christopher DL/ID: 351AE3858