HomeMy WebLinkAbout16-163CITY OF IOWA CITY
410 East Washington Strcel
Iowa City. Iowa 52240-1926
(319) 3S6-5040
(319) 356-5497 FAX
IDENTIFICATION NO -
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review mast 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)
2. Address (REQUIRED) (ql
3. Contact Information (REQUIRED) Email:
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of ps
-I Phons: I S
-S0 "LfI
sent via email)
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this Stale or elsewhere?
What happened to the charge? (Circle one)
Convicted Dismissed Dfern Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
vvnat happened to the char e'? (Circle one)
Co vi ed 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? n
Type of offense
Where
When
ro
co .
9. Have ypu ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the oalne(s) i {
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIEM
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 y n that I J a iss�ed to me by the Iowa Department of Transportation a valid Chauffeur's license number
Q, issued onj- 1 5 expiring on (7 Z-7 7 . I understand that if
fals ly answer a y questions rn 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 relatingthis application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the Pr6vlstons of Title 5, Chapter 2, of the City Code. (Needs to be signed In front of a Notary Public)
Signature ofApplicarkk71/aV a Date2- 7
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this 2-,1 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).
license 0 1' 7 L v�w
or designee
Date
AFTER APPROVAL BY THE CRY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Ae. K� fi1J
Sign re of City Clerk or designee
ate
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Office Use Only
Approved application
DCI report _
State certified driving record 7
Website update n>
CaWr/WORIVBPDGFJwPL•sloleammam.WC ' n, 0312015
IN 1. 21• LU 10 Y:]4W VIv 01 Lrimindl Investigation No. 9911 P. 2/1
PgornpClay' or Iowa Gay Clerk OHlea 319 3e&6497 09115/mole 09:90 8436 P.OoWooa
STATE OF OWA
,
HistoryCriminal
Yr '.Rzquestt' ��",••odl �•.
To: Iowa UWision of crimInaIInvtstigation
Support OpermionsBureau, la' Floor
215 E. 71, Bisect
Des Moinvs, Iowa 50319
(515) 725-6066
(515)725.6000 Fax
I mn raauestinv an lawn Criminal 14;0n,v A.r.ntd Ph..I,
DCI Account Number: L -+b 2 --z._-!-•
(it appnonbm)
From: —Cits, City _
City Cleric's Office
4101:. Washington Street
Iowa City, 1A 52240
Photic: 319.3565041
part 319-356.5497
Last Name(maodatory)
First Name (nlandato )
117Jddle Narue recommended)
Date ofBirtlf mnnducry
Gender (mandato)
Social Security Number (racommandad)
1-��' 1DMale
❑Fctuale
���,— /�I'�'��
ifWAiyePrilfOPglnfioll. Without a signed waivtr from the subJcet of the request, a complete criminal history record may not
be releasable, per code of Iowa, Chapter 692.2, For complate criminal history t'eeord inforinatlon, as allolved by law, always
obtain a welver sl nattn•o from the subject of the request.
WR1VEr %felerrSea hercbp give perms 1 nfor the ebore[tqumiog arDcirp to conduct all low.uimi,ml history rcwid cbcck uiih she bivbtao or Criminal
htvutigatia, (11C0. Myvunouihistcrydal e a ruing me dlnthmeintaiucd by the DCBn�l ha releosed as atlevcd by torr.
(�afverS1_erllrftr ,
,—
at+uarrt0! l<l.eJWL Y r•\Cl:UI-U l.I14:CJ1L J.CC2JU1[S _ a' (p C-,�lY)
As of _ i 1 a search of the provided name and date of birth reve led:
P,1.
Cn
0 No Iowa Criminal liistury Record Cound with DO
Iowa Criminal History Record atlaclaed, DCI # I d 3 ` cu . • CD
rr,
DCI initials R
DC:1-7/ (0125M)
Received Time Mar, 15, 2016 9:17AM No. 9609
Mal•'I., 2016 9:34AM Div of Criminal Investigation
Ro.9911 f'. 3!3
IOWA CRIMINAL RISTORY
DCI 00669031
NON CONVICTION
PAGE 1 OF 1
DATE PRINTED-
DCI:00B69031 2016/03/21
NAME: MAZOA9,33USTIN ROY
DOH SEX RAC HOT WGT EYE RAIR SKN POB
19900123 M W 602 220 HAZ SRO VT
ADDITIONAL IDENTIFIERS
CCR RECORD +44
Ol ARRESTED 20090604
AGENCY: IAD5702oo MARION PD
CHARGE NO- 01 IA STATUTE IA124.401(5)
P029ESSION OF A CONTROLLED SUBSTANCE
TRX#: SA006ECol
COURT DISPOSITION
AGENCY: IA057015J LINN CO DIST COURT
COUNT NO- 61 IA STATUTE: IA124,401(5)
POSSESSION OP A CONTROLLED SUBSTANCE
COURT CASE ID: 06571 SRCROBS539
CHARD£ CLASS: NON CONVICTION
TRK#: 5A006EC01
SUBSTANCE ABUSE EVALUATION
SENTENCE DISP EFF DAT
DEFERRED JUDGEMENT lY 20090910
PROBATION lY 20090910
DISCHARGED FROM 20100311
DEFERRED JUDGEMENT
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION
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iLDOT
wlnnV.iowadaiagov
Office of Driver Services
PO Bob 9204 Des Moines IA 50306-9203
Phore. 515.244.9124 1 800.532-1121 1 Fax. 515-239-1837
waw kiwadw.gov
Certified Abstract of Driving Record
Inquiry Date:
3/15/2016
DL/ID #:
134CCO201 (IA)
CDL Permit Class:
None
Customer #:
4544774
Class:
D
CDL Permit Issue
None
under In
35-55 mph zone)
Benton
IA
Date:
10/24/2008
Name:
Mazgal, Dustin Roy
Audit #:
8963357
COL Permit
None
12/11/2008
12/30/2008
592
Speed (10 mph &
Expiration Date:
35-55 mph zone)
Address:
1913 FLATIRON AVE
Issue Date:
03/28/2015
CDL Permit
None
under In
35-55 mph zone)
Linn
IA
Endorsements:
07/19/2011
S92
Speed (10 mph &
Expiration Date:
01/23/2022
CDL Parmit
None
02/06/2013
03/18/2013
S92
Speed (10 mph &
Restrictions:
35-55 mph zone)
City/State:
IOWA CITY, IA 522405961
Endorsements:
3
ID Status:
None
Mailing
1913 FLATIRON AVE
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Melling
IOWA CITY, IA 522405961
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/23/1990
CDL Cert Status:
None
Sex:
M
CDL Mee Status:
None
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
07/18/2008
08/27/2008
S92
Speed (10 mph &
under In
35-55 mph zone)
Benton
IA
10/08/2008
10/24/2008
592
Speed (10 mph &
under in
35-55 mph zone)
Linn
IA
12/11/2008
12/30/2008
592
Speed (10 mph &
under In
35-55 mph zone)
Linn
IA
07/26/2009
08/24/2009
S92
Speed (10 mph &
under In
35-55 mph zone)
Linn
IA
06/26/2011
07/19/2011
S92
Speed (10 mph &
under In
35-55 mph zone)
Washington
IA
02/06/2013
03/18/2013
S92
Speed (10 mph &
under in
35-55 mph zone)
Iowa
IA
Name: Mazgel, Dustin Roy DL/ID: 134CCO201
Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that 3
am the custodian of the retards 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:
n
tie@%3/15/2916
IOWA T...-
40
-€ Office of Driver Services
`�w....� Iowa Department of Transportation •-
Name: Mazgaj, Dustin Roy DL/113: 134CC8201