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Home My WebLink About16-164IDENTIFICATION NO. / Lsi — I l.0 `f l 1 (Office Use Only) CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319)3S6-5497 FAX c First Middle I_ Last 1. Name (REQUIRED) `, ��cn n a )"t rcry); jjs nI l 2. Address (REQUIRED) -,�-:!s44 T� C% LA Q S S JTZ P i 3. Contact Information (REQUIRED) Email:Cell Phone3(j, �ci )• Ga �� (All written communice ion se t via email) 4a. Driver's License expiration date (REQUIRED) q I / R I /+ L b. Taxicab Business Name (REQUIRED) y�l�V jt �� / 5. Prior experience in transportation of passengers: JR 14 S d r I i e r A 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? e— Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged With any traffic offenses in the last five years? n b 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? n C) Tvoe of offense Where Wherr a pa 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(sh DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE. CERTI)' D 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 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number —&amS `� � \�T-7 issued on 8. 1 9 , 14- expiring on � , 1 $ t ) &, . 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicantol� Date Oa 3 1 }If###1fYYFY#Hf11Hff}f f-#}!F#+i4Y4#44Yff11flHf iff ffl+}+#}f#}+#44fYf1flT11fT1m}flTf}f++}+Y}#Y#flflffHlNflflHflf}+}}+i}Y#YYYf1111ffff111f1f STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by c:-,,4:5eutron this -Z day of ,A% 20110 1VWENDY SR Notary Public i and for the Sta of Iowa My RR*1eRRRf+444R#f#1144**i***#R***R**##*RR#4484+4*#*********R*R***#R44RfRff*ffflff#f#i#f4**#**#*****####RRRRR#RR#RR#Rfm#*m***R***RRR*1****1RR#R 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). 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. Sighature of City Clerk or designee �A/- Date ###+4111+f##14141 1f f ff 411r4m1.#++fafmff1mf144TTm«.1..:}+YY}#1411 f 1141!lf4flTf4ffmmm}41ffm1fYf11ff N C� Office Use Only _ m 4� G Approved application DCI report State certified driving record -° Website update w J Cn 0&WTAXIDRN94DCEAPPL92010e, dW.DDC 07/2016 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. Sighature of City Clerk or designee �A/- Date ###+4111+f##14141 1f f ff 411r4m1.#++fafmff1mf144TTm«.1..:}+YY}#1411 f 1141!lf4flTf4ffmmm}41ffm1fYf11ff N C� Office Use Only _ m 4� G Approved application DCI report State certified driving record -° Website update w J Cn 0&WTAXIDRN94DCEAPPL92010e, dW.DDC 07/2016 Aog.19. 2016 11:28AM Div of Criminal Investigation No. 1065 P. 2/4 11-11 — — ._.i.y 0Ie14 VIIIVq 'J IV Sb gg4H/ 015/17/2019 12:07 *631 P.002/002 STATE OF IOWA , Crl mi ina9 History Record Check l � � Request IN1orlma s To: Iowa Divisirn of Criminal Investigation Sapport Operstlons Bureau, I" Floor 215 B. 7d' Street Des Motiles, Iowa 50319 (SIS) 725-6066 (SIS) 725.6050 Fax I am rcquestine an A dwR t., °`7V)J` //lz 55 ❑Male ce I( 3iq-3ai 6a DCI Account'Nulnber: (itappliepble) From: City of Iowa Cit City Cleric's Office —�--- >310 E. Vdashin ton Street Iowa City, IA 52240 Phone: 319-356-5041 FAX: 319-356-5497 SocialSecurity Number (recommende Wal Vey Information: Without a signed waiver from the sobJeci of the requ ail, a complete criminal history record may not be releasable, per Code of Iowa, Chepter 692.2. For complete criminal history record information, as allowed by law, Always obtain a waiver slYnattlrp.. frnin lisp tuhipte of eh. r.n..n.. AVaiver Release: I h.mby give pemrission for she abort requesting official to canduc) on lags cflbrinsl historyrecord ehcch Ivilh est Division or Criminal 11%rWigatiml (DCI). Any eriminsl history dam coneenling me chat Is main,alned by list DCI nlay be released as allowed by law. l�YafV@YSignafnY@: (�/1. ,,.j) . •f Iowa � Criminal Histo Record Check Results (DCtuaeonly) As o£��_/ 17, a search of the provided name and date of birth revealed: No Iowa Criminal History Record Found with DCT >s. -71 Iowa Criminal History Record attached, DCT # 1.. l DCI 1111tIA15 O DCI -77 (08/25/10) Received Time Aug. 17. 2016 11:50AM No. 192 C,410WA DOT IMPLER I CUSTOMER DRIVEN vuvvw,Iowadogov SMARTER I 5 0 Office of Driver Services PO Box 9204 1 Des Moines, IA 503069204 Phone: 515-244-91241800-532-11211 Fax: 515-239-1837 www.lowadotgov Certified Abstract of Driving Record Inquiry Date: 8/19/2016 DL/ID #: 555YY9675(IA) Customer #: 1823761 Class: C Name: Middaugh, Susannah Marie Audit #: 1097699 Address: 334 DOUGLASS ST Issue Date: 06/22/2016 CDL Status: None Expiration Date: 07/14/2024 City/State: IOWA CITY, IA 522465408 Endorsements: NONE Mailing 334 DOUGLASS ST Restrictions: Corrective Lenses Address: Restriction None Mailing IOWA CITY, IA 522465408 Supplement: City/State: Date of Birth: 7/14/1955 Sex: F History Information CLEAR DRIVING RECORD Name: Middaugh, Susannah Marie DL/ID: 555YY9675 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 DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: Excepted Intrastate CDL Med Status: None 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: s4',`�:" .t'fG8/19/2016 (4- of Driver ,4.P�£ Iowl aeDepartme teof'Transportation o rn C •� Name: Middaugh, Susannah Marie DL/ID: 555YY9675 N•- C]