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Home My WebLink About16-1611 r CITY OF IOWA CITY 410 East Washington Streel Iowa City. Iowa 52240-1826 (319) 3S6-5040 (319) 356-5497 FAX IDENTIFICATION NO. IU/ — l' �4 1 (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 1. Name (REQUIRED) First OliMiddle �t�a a m i e-LastKc o tt 2. Address (REQUIRED) 3 So 3 Sha mL rocK-e L- q 3. Contact Information (REQUIRED) Email: 1011 rA S C0 I' '1q C qct I •don`iCell Phone: 30 4eq ',31 y (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) Q It ouJ C.bl b 5. Prior experience in transportation of passengers: f4 DNP -i rn 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this Staig W Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty Other�ONA'` Have you been arrested/ charged with any traffic offenses in the last five years? )rl Type of offense Where When 113OR1�OPr QrAIS�✓�i�to✓1� )—ale' IS 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? 4es Type of offense Where TA When Is 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereLt by c@@t that I have{t issued to me by the Iowa Department of Transportation a valid Driver's license number p l cc S c o issued on S11 j(* 12olu expiring on G 1 15 1 1(0 . I understand that if I falsely answer any questions in this application, that this applica ion 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) 4###44YYHHlHfHlRIHR!!RR!#HH4Y##HHlHY!#YRHR4R1**R!#1R##*##H##H##4HHHfl44fRlR!*RHRR#f#;#####44H4HR#HifHff 1f!ll1RRR#R*#*###H# STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by i{ on this Z�_ day of Alt� 9oll a. MKM _ I Notary Public in(agld for 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 Signature of olic hief or designee 4zzA)�_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. �1, / X/ 2, S'ignatsre of City Clerk or designee Date' ;1f1111H1f 1f;Hfi: fiYHHf#iYff111111;1RH;;;1f+f+#1H#H#4R1flYffflHHf;1!111;H+HHH#HfHHYR1111fM1fff 11HlHfllflf lfllflH+Hf}1f}H#+# 0erk/rA%IDRN1SDGEAPPL9401dem de0.DOC 07/2016 Office Use Only ^) 0 Approved application =7 DCI report —>-, ri State certified driving record c-) ^� Website update<r- -;c r �I 0erk/rA%IDRN1SDGEAPPL9401dem de0.DOC 07/2016 oe/Aug�16. 2016112:27PMceb Div ofCriminalInvestigation No, 0930 (FAX)3193382'iuo STATE OF IOWA Criminal History Record Check Request Form ! 1, Tor Iowa Division of Criminal Investigation Support Operations Buroau, 1tt Floor 215 E. 7'h Street DoliMolnes, Iowa 50319 (815) 725.6066 (SIS) 725-6080 Fax T .. -.....ae,rnn wn ln.,.. /y.r...l...r Crl.i-,-. Tf ----J nL--6 --. P. 1/4 v.uue/002 DCI Account Number: _9967-F arepplleable) From. Yellow Cab of Iowa Clty P,O. Box q28 Iowa City, U. 52244 (319) 3389777 Pbonat Fax: (319) 339.7302 Last Name tmrndawrr) Flret Name manduo ' Middle Nf4mo (feeomme' ded) , Date of Birth hnmilmo Gelid or mandato -So sial'Security Number (recommended 5- r �a~$a � ❑Male M!Femtile Walver Xnforinallonl 'Without a algned waiver from the subject of tho request, a compigte crlminal hlatary record may not be roleasoble, per Coda of lova, Chapter 692,2, 17orglimplete criminal hiatory.record Information, an allowed by sow, always obtain a waivers) nnturo front thanub act of the request, l' UIVerAelease: I hereby give pom,lallon hr rhe above requodna official to annduer en lows crimteel hlstory record eheokwllh the Dlvblon ofCominal inveadtadon (DCl), Any criminrl himary dais eonoamin`me shot Ir-m-a�iyn-ulnad by the DCI may be releered as anowetl bylaw. Walver Signature, (DCI uta only) As of a search of the provided name and date of birth revbaled: No Iowa Criminal History Record found with DCI <r• l ❑ Iowa Criminal History Record attached, DCI #� C-:1 DCI Initials DCI -77 (08/25/10) Received Time Aug. 16. 2016 2:18PM No. 1793 ClJ10WADOT wvvw,iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN Inquiry 8/16/2016 Date: Customer 5361070 Name: Scott, Lolita Jamie Address: 3503 SHAMROCK PL City/State: IOWA CITY, IA Convictions Office of Driver Services PO Box 9204 I Des Moines, IA 50306-9204 Phone: 515-244-9124 1 800-532-1121 I Fax: 515-239-1837 www.iowadol.gov Certified Abstract of Driving Record DL/ID #: 522455137 Mailing 3503 SHAMROCK PL Address: 1008577 Mailing IOWA CITY, IA City/State: 522455137 Date of 5/22/1982 Birth: Restrictions: Sex: F Convictions Office of Driver Services PO Box 9204 I Des Moines, IA 50306-9204 Phone: 515-244-9124 1 800-532-1121 I Fax: 515-239-1837 www.iowadol.gov Certified Abstract of Driving Record DL/ID #: 211AD0808 (IA) Class: D Audit #: 1008577 Issue Date: 05/17/2016 Expiration 05/22/2018 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: CDL Permit History Information CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: None OL Status: VAL CDL Status: None CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None :nation Date Conviction Date ACD Explanation County JUR 11/26/2015 102/22/2015 I (Improper Registration (Johnson $A Sanctions type Effective End ACD Explanation Occurrence JUR JUR >uspended low 2/2015 104/18/2016 !053 140n4ayment of Iowa Fine IA IA Name: Scott, Lolita Jamie DL/ID: 211AD0808 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: ...yy _`aQV�.CIf.& 16 8/16/2016 Office of Driver Services Iowa Department of Transportation Name: Scott, Lolita Jamie DL/ID: 211AD0808