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Home My WebLink About16-121CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) _ IDENTIFICATION NO. J 1,e — % Z I (Office Use Only) APPLICATION FOR TAXICAB I 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 Middle J Last O 2. Address (REQUIRED) 1'l 'Mo,,kP:fi1 t.R-" r��c l_ �VA S2al-io 3. Contact Information (REQUIRED) Email: 2i1n! lCyl 3(�! u� rom Cell Phone: (All written communicate n sent via email) 4a. Chauffeur's License expiration date (REQUIRED) n I C q I) b. Taxicab Business Name (REQUIRED)_i(�d1y7S�G C�1� 5. Prior experience in transportation of passengers: 1>Twe�r 1,EK, l v �; �i1� ,r r,-fs 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? nom? 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 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? A/0 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 thearme(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE.CERTIFlf�D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available uponrequest). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that the Iowa Department of Transportation a valid Chauffeur's license number htgA,d ) issued on (I have issued to me by77%drf/ra expiring on dj/d9/!-? . 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 allev✓ 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 r Date !b STATE OF IOWA ) COUNTYOFJOHNSON Su scribed and sworn to before me by UJ V �jC iC V\—on this �� day of C_ t _ KELLIE EKTUT� _ e19 l + r -1 is Public in and for the State of Iowa 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 35 111t - Signature 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 / % �1 � Dart r-� Office Use Only Approved application – DCI report State certified driving record Website update clerWrAxIDRm6ADGE PPL92014ameoded.Doc 03/2015 C vvww,iOwadOtgov SMARTER I SIMPLER I CUSTOMER DRIVEN.. 4..a..o..�:�_.. Inquiry Date: 6/21/2016 Customer #: 5996600 Name: O'Brien, Matthew Joseph Address: 77 MODERN WAY City/State: IOWA CITY, IA 522403070 Mailing Address: 77 MODERN WAY Mailing IOWA CITY, IA 522403070 City/State: Date of Birth: 7/9/1984 Sex: M Convictions Office of Driver Services PC Box 9204 1 Des Moines, IA 50306-9204 Phare. 515-244-9124 1300-532-1121 1 Fax: 515-239-1837 www.wvradot.gov Certified Abstract of Driving Record DL/ID #: 614AH7688 (IA) CDL Permit Class: None Class: B COL Permit Issue Date: None Audit #: 1024600 CDL Permit Expiration None Date: Issue Date: 05/24/2016 CDL Permit None Endorsements: Expiration Date: 07/09/2017 CDL Permit Restrictions: None Endorsements: PS ID Status: None Restrictions: CDL Intrastate Only, No Air Brake DL Status: VAL Equipped CMV, No Class A Passenger Vehicle Restriction None CDL Status: VAL Supplement: COL Permit Status: ELG History Information CDL Cert Status: Non Excepted Intrastate CDL Med Status: None :itation Date Conviction Date ACD Explanation County JUR 12/06/2012 01/08/2013 S92 Speed Johnson IA 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 %vitness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: WVI IOWA wx J-1 6/21/2016 O f......._ RRialk Office of Driver Services =- +Nsv�„�� Iowa Department of Transportation JLL. 24. 2016 2:11PM� o Div of Criminal Inv estigaliur o� 2OY s �Fsy No�7053P, 1%1 Boz STATE OF IOWA <roirc� Ch-i'llinal History Record Check l Request Form <' To: lows 1)ivlslmt of Criminal tuvostigation Support Operations But -am" I" Floor 215 E. 711 Street Des Moiues,Iowa 50319 (515) 725-61166 (515) 725.6090 Fax I am requesting an Iowa Record amc au: UCIAccount>\umbcr'_ f•�C�'z,--� (if applicshlt) From: C of Iowo Ciiy City Clerh's Office-��------ A10 E. I'm 1, top Street 10wh City, JA 52240 Phone: 319-356.5041 Fax; 319 -3S6 -5T97 - MA144Ie ❑Female I :?-�7 - 7L/" Lls'/o rrarver injDrp9rlf/ori.• without a signed waiver front the subject of the request, a cmnplete crimAlal history record may not be releasable, per Code of Iowa, Chapter 692.2, icor eonlnlete criminal histoq- record lilfOrmation, as allowed by law, ahvays obtain a waiver signature Iron) the subiect of thw rnmrree 4" dVer Release; l hcfcuy give permission for the abavc Iquec[iag oif till to conduct an town crimiesl history record cbwk withdm Di, isioPor criminal L vestigation (DCI). AP), criminal history date concerning me 11121 is maimained by the DCI cony be «leased as allowed bylaw. IYadverSLglfdfiere __ , , Iowa CriminalHistor ]record Check Results As of� a search of the provided name and date of birill revealed- r Na Iowa Criminal I4islory Record fowftl with llCI �• ❑ Iowa Criminal history Record al(ached,l3CI #__ C) DO initials DCI -77 (09/25/10) ------y _ Received Time Juh,21, 2016 2 : 5 2 P M No. 8022