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Home My WebLink About16-132rIr CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 3S6-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED; IDENTIFICATION NO. 11 -- 7) Z (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 wiU result in denial of the application 3. Contact Information (REQUIRED) Email: 14P?. 2\Ayvnrri�na \•Zee Cellphone: c319t(cjl.3(((r�j (All written communicatio sent via email) 4a. Driver's License expiration date (REQUIRED) aS % aC) b. Taxicab Business Name (REQUIRED)_ �\�Zw C 210 J- 5. Prior experience in transportation of passengers: -) hV � l lSzs *animas 1 r r1 �� . _ •. . 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?_ Type of offense Where When What happened to the charge? (Circle one) i Convicted Dismissed Deferred / SuspendedPlead GLiiiV Other Have you been arrested / charged with any traffic offenses in the last five years? S Type of offense �W Where When m 6 ea IeMp4,-i vrd-�, l,zitMt� Co ^Lti Wali Il, What happened to the charge? (Circle one) onvicted Dismissed Deferred Suspended ��etruOther Has your driver's license or chauffeur's license been suspended or revoked in the last five years? �7 Tvpe of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide thei_name(s) Kj (3 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIF1 ` DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available upgn,request- (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) ra 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Paegge 2 I hereb certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number 6oZ 7 X -tSS-a issued on C),;?Dd xpiring on 0 1 / ;�S ( a . 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 provisio0s of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by �ut<u UA. y C - L+e LQ` on this _Z day of �filk, 7w11 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 Driver's license I / Z�5� u Signature of Poli C ief or designee A. 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. ig ture of City Clerk or designee ate w Office Use Only Approved application DCI report State certified driving record Website update CleM1 71ORIVB DGE PPL92014aiaiended.00c 07/2016 ii 111b 410 ILI T SMARTER I SIMPLER I CUSTOMER DRIVEN,,., V00wadot•gow Office of Driver Services PO Box 9204 ( Des Moines, IA 5C306-9204 Phone. 515-244-5124 1800-532-1121 i rax: 515-239-1837 Www_Eowaclol gov 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 sD certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon this documi Ankeny, Iowa this date: V4NIC(f0id,/o4, Certified Abstract of Driving Record 7/21/2016 Ie Inquiry Date: 7/21/2016 DL/ID #: 582 xx4552 (IA ) CDL Permit Class: None Customer 4028803 Class: D #: CDL Permit Issue None Name: Leech, Autumn Christine Audit #: 9752862 Date: CDL Permit None Address: 931 1/2 N DODGE ST Issue Date: 02/02/2016 Expiration Date: CDL Permit None Endorsements: Expiration 01/25/2018 Date: CDL Permit None City/State: IOWA CITY, IA Endorsements: 3 Restrictions: 522455911 ID Status: EXP Mailing Address: 931 1/2 N DODGE ST Restrictions: Corrective Lenses DL Status: Mailing IOWA CITY, IA Restriction None Supplement: CDL Status: VAL None City/State; 522455911 CDL Permit ELG Date of 1/25/1987 Status: Birth: CDL Cert Status: None Sex: F CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation 11/28/2013 .01/20/2014 592 Speed p County )DR 05/06/2016 06/21/2016 / S92 Speed (10 mph & under in 35-55 Jasper IA mph zone) Clayton IA Name: Leech, Autumn Christine DL/ID: 582xx4552 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 sD certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon this documi Ankeny, Iowa this date: V4NIC(f0id,/o4, IOVVA`z., 7/21/2016 Ie DRIYt� S Office of Driver Services FrcJU I. ICr LVIUv J: L9 fIVI,iernb 07/16/2018 Nu0.. hl - H 1;`I STATE OF IOWA 2� Criminal History Record Cheep Request Fore To: Iowa Division of Criminal Invesligadon Support operations Bureau, 0 Floor 215 L. 7rh Street Des hloines, Iowa 5U319 (515) 725-6066 (515)725-60@0 Fal: I min renuestinu nn Inwa Criminal Hicfnktt RPrnrd r'6P�L DCI Account Number, _qoo�)' (itapplimMe) Crum: -city of Iowa City _ City Clerk's Office 410 E. Washington Street lova Ci(y, IA 52240 Phone: 319-356-5041 Fax: 319-356.5497 Last Name (nandmory) First Name (mandalory) Middle Name 0"ommcndcd) Date of Birth (mandatory) Gender (mandatory) Social Security Number lirdCUMndaj C) (a5 1 r °I 5-- ❑Male Waiver rnforniatioa: Withoutat signed waiver From the subfect of the request, a co,nplete criminal history record may not be releasable, per Code of Iowa, Chap(er 692.2. For complete criminal history record information, as allowed by law, always obtain a Waiver signature 11rom the subject of the request, WalVer Release: t hereby give permission for the above requesting officinl lo wnducr an lova criminal historyrecord check wilt the Division of criminal trteesligatim+(IM). Any criminal history data eanaemin me/jrI is maimaired bytllepct maybe released as allowed bylaw. Waiver Signature: Iowa Criminal History Record Check Results (DC, use only) 9� 1 qq CJ As of -- a search of the provided name and date of birth revealed: ") r No Iowa Criminal History Record fount) with DCI L 0 Iowa Criminal History Record attached, DCI # DO initials /�-, Vim' c ULA -n LU 612 nut w Received Time Jul. 15. 2016 2:41PM No -6455