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CITY OF IOWA CITY
410 East Washington Strect
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. Lg (71j6ri
(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
J5` Wk
Middle
Last
G Lama 1,�, } S$ . .tat -�.G v� r� sZz.�
3. Contact Information (REQUIRED) Email: 1t J i tf05 %cv f LrG'� gip) Cell Phone95(.2_265'_
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) O y - Z S - 2 c) ) -7
b. Taxicab Business Name (REQUIRED) _ Aikfn )S 6 f(I Ca j� Ga
5. Prior experience in transportation of passengers: VBcar-5 c, -I— lyCaplw>
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /�/C)
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? )k-- S
Type of offense
Xo
What happened to the charge? (Circle one)
Where
C `,4
When
/ 3. 2-D
Convicted Dismissed Deferred Suspendedlead Guilt Other _
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /ti C1
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 d ifne s
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFjfD
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 VL-"HICLE DRIVER
Page 2
I hereby
lcerci ghat IIhave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
o2 , C, x y7 issued on 6-tJ, 2612 xpiring on q-ZS,,?_OI --? . 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 provision of Ile �, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant � . Date S-1 —3 , %iI
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by SOt, �A. i c�. L��k� SIC on this r: 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
Signature of Police�edesignee
G
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
Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update r
ClerkrrAXIORN9AOGEAPPrs2014amlnded.DOC 0312015
cis tMay.10 2016) 9:41 AM Div of Criminal fav estigatioo DC1 100L,' 4691 F.` lob
3�
STATE OF IOWA
Criminal History Record Check
Request Form
Tor rowa Division of Criminal Investigation
Support Operations Bureau, I" Floor
215 & 7" Street
Det Nolues. Iowa 50319
(SIS) 7356066
(513)7354060 Fax
DC! Account Nwnber; 383 - FL
-� Ilfow.. Ye)
From: _♦' aaY 5'5')(l
AXl
ll6 54-cl m r.
Phoact 0(4) 338- I
Fast. -f 314 351-
I aro roguesft an Iowa Criminal Oslo Record Chock on:
Last Name mwdew ) First Namo lmwrdroory Middle Name mmmmnd
L<}SuoW5i�l JOSEp�I 4.JgLTa,
5aJ'i o
Gy . z.'!�-, / 9 73 J manie ❑Female 1 10% S-2-3 32 7 - - 1
Waiver lrirarrrtatiodt without a rlgDed walver from the subject otths nqueel, a complete criminal blatory record way not
be releasoble, per Code orrows, Chapter 692.2. For saAVftoHminal history rewrd latormodon, u allowed by taw, always
ebtde a waiver sl®atare Orem the ambiart of the �—t
nMlplin(M). r:7hereby give perdnk for Uq Wove Ngr�minsonkW to eOW=rn Tawe uimi'd hurnry,wort cheek wish the Divitton ofCombul
Invmuplion D)cq. AOY crimiod hiaary deti m"c�rb6 —'Mt h rralnuinoa by the DCT may be teteaud a diowed by law.
TOW$ Criminal History Record Check Results MCI uw oNy)
As of S a search of the provided home and date of birth revealed:
j No Iowa Criminal History Record found with DCI
Iowa Criminal History Record attached, DCI
DCI initials 0
CS: C:
DC1-77 (09/25110)
ut
Rectived Time May, 2 2016 10:06AM No. 3548
.r DoT
SMARTER 5�PAN t`P Iiit'i�,`-w
CJffife of Inver Servlce5
PO 8+ X21,4 Des kjo n,.s,. In 50 fl'6J 9203
Phone t!5-244-9124 E4 .2-:1291 far 515-23_-9337
w'ww.lo',s'S dot: gtrv.
Certified Abstract of Driving Record
Inquiry Date:
5/12/2016
DL/ID #:
127ACS472 (IA)
CDL Permit Class:
None
Customer #:
5231945
Class:
D
CDL Permit Issue
None
of Driver Ss
eof lTr
IIoweDepaartme t
aansportation-
r
Date:
Name:
Laskowski, Joseph Walter
Audit #:
5981226
CDL Permit
None
Expiration Date:
Address:
836 WALNUT ST
Issue Date:
05/15/2012
COL Permit
None
Endorsements:
Expiration Date:
04/25/2017
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522403340
Endorsements:
3
ID Status:
None
Mailing
836 WALNUT ST
Restrictions:
Corrective Lenses
DL Status:
VAL
Address:
Restriction
None
COL Status:
None
Mailing
IOWA CITY, IA 522403340
Supplement:
CDL Permit Status:
ELC
City/State:
Date of Birth:
4/25/1973
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
'Ration Date
Copv;c:ion D1 t'z...
,%ia
=<I d z . �znn
County
3UR
)9/13/2013
10/02/2013
S93
Speed
Johnson
?IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident slate Cse P3urss3rs..�
09/07/2012 ...... , ,. _. ... ..
_....... 703362 LA ..IA
09/13/2013 X757141 IA 'I
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
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: Laskowski, Joseph Walter DL/ID: 127AC8472
n.,
:O@ •......./ryr
5/12/2016
*; Iowa'':
4y D. 0. T.;.�- <
�
;,
rr'r..�y
of Driver Ss
eof lTr
IIoweDepaartme t
aansportation-
r
Name: Laskowski, Joseph Walter DL/ID: 127AC8472