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Home My WebLink About16-169� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319)356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) 3. Contact Information (R IDENTIFICATION NO (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 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) % r3' 201 f b. Taxicab Business Name (REQUIRED) t 6(hu) CQ 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When -C 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? Type of offense Where when What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? No 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 thejriame(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTI4D 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 - 5 5 a a L( l 0 issued on :1 -L2. 16 expiring on 7. 2- 10! $. 1 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 Applicant Date F'- Z S - /6 4+#4fiffYf}iif!!lfl44fi41f!!!llflf****#***f+#*+##+####iYi}i#}#Y}4ifi##Y#f}441fi4H1ff1fflltf!!H***i***f+f#*f**#*f*f*#*f**ff#+#}+##}}HfiY#}M4f STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by &,,3row n NA • 4cu S 3 on this day of Public in 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). of Dri I license p.Zr-�� z 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. h3 KI . Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update �-as- Date Ca'Vr 1DRNOADGEAPPL9201Cam dWDOC 07/2016 Oe.Aog• 18. 2016512:27PMcebDiv of Criminal Investigation (FAX)3193382No.0930 ;.. OF • WA CriminaloryRecord Reques0hrm Tot Iowa Dlvl#lon of Criminal Investigation Support Operation# Bureau, in Floor 215 9.7'h Street Des Molne#, Iowa 50319 (515) 725.6066 (S18)725.6080 Fox I em ranuestin2 on MwA Criminni 1:1 Meru hA.nnA rt..,.t.... P.� 2/41/002 DC1 Account Number: _4_,_,9967-F ' (Ifappllcable) Proms YellowCab of Iowa Clty P.O. Box 428 Iowa City, IA. 52244 (319) 338.9777 Phone: Fax, (319)339-7302 Last Name mandato) Mrst Name mandato ' Middle Name (reoommendod) H Date of Hirth mandatory) Getider manduo 'Social -Security Number recommended (��•0:5-7q 59maie (]Fomale 32l'e.1-SrQ�3 Waiver Xpjormadonr Without a signed waiver from the subject of the roquost, A compigto grlminal history record inoy not be releasable, per Code of Iowa, Chapter 6912. For cam plotcriminal hlatory,record information, as allowed bylaw, always obtain a waiver signature frotn the subject of the request. Wt barReleasg:Iherebyalvepermhtlonmrthonboverequvllneo OB, to conduct an Iowa criminalhinatyrecordcheekvAthdig Division ofcrhn,nal Invatlaatlon(MI), Any crintinol history date conomiltig me shot is molpiatnod by [he I)CI ropy bo ralBased as allewol by law, WaiverSlgnarure: /4.._2 lows criminal History Record Cheek Results r s: (0cluse only) As of , a search of the provided name and date of birth revealed: — o' No Iowa Criminal History Reoord found with DCI r Iowa Criminal History Record attaohad, DCI # 1102 ylo cn a DCI lnitialo Dol -77 (08/25/10) Received Time Aug, 15. 2016 5:02PM No. 1736 Aug. 18. 2016 12:28PM Div of Criminal Investigation No. 0930 P. 3/4 IOWA CRIMINAL HISTORY DCI 00802469 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 2 DATE PRINTED- DCI,00802469 2016/08/18 NAME: HOUSE,ANTONIO MAURICE DOE SEK RAC HGT WGT EYE HAIR SKN POE 19790703 M E 601 185 SRO ELK BLK IL ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y TAT L SHLD TAT R SHLD CCH RECORD *** 01 ARRESTED 20070514 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA708.3A(4) ASSAULT ON PEACE OFFICERS & OTHERS TRK#: lAO01GO01 COURT DISPOSITION AGENCY: IA05201W JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA708.3A(4) ASSAULT ON PEACE OFFICERS & OTHERS COURT CASE ID: 06521 SRCR079511 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: lAO01GO01 SENTENCE DISP EFF DAT TIME SERVED 9D 20070815 JAIL 9D 20070915 FINE $315 20070815 02 ARRESTED 20070625 AGENCY: IA0520200 IOWA CITY PD CHARGE 140- 01 IA STATUTE IA321J.2(A) OPER VEH WH INT (OWI) / IST OFF TRK#: 1A001QS01 COURT DISPOSITION AGENCY, IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321J.2(A) OPER VEH WH INT (OWI) / IST OFF ' COURT CASE ID: 06521 OWCRO79906 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 1A0010S01 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT JAIL 2D 20071017 FINE $1250 20071017 03 ARRESTRD 20081023 AGENCY: IA05201DO CORALVILLE PD CHARGE NO- 01 IA STATUTE IA708.2A(2)(B) DOMESTIC ABUSE ASSAULT WITHOUT INTENT CAUSING INJURY TRK#: IAOOSFI01 ' NOIS,YDISSHANI 1YNxWIu0 30 NOISIAIa 'AUInONI 3nOA do S03PHnS 3HS $142%00 mdomN aHs iHHS AN3a 'do Wdxmw ION= sM 'aaHsiNNnd NOISYwaoANI NO a3SYS SI adOOSH SIM! NOItV0Id1,LN3aI HAIIISOd Hod SINIHdXSDNId d0 30HURV 9Hs NI 'xaa mu AS SHIONaDY INawaDaodNa MVI -NON OS aaSYaUHH ss 47NO NYD Ing adODU DI'isnd Y SI NOISYDISISN3aI 30 nYadnS 'NOI1VDISSHANI RYNIWINO 30 NOISIAxa Y901 3HL AS a3NIY,LNIYW UHO0ZH SIMS 'S'IIOD 40 NOI,LYDIONI NY SON SI NOI.LISOdsIa SnOHtIM IS3li14Y NY SZ60600Z OOT$ aNId SYa dda aria aONaSNaS TOAM900VT :#XNIL NOLLDIANOD NOMYSW2a6IW t MID 3E)MD 69TL8O'd0HS TZ990 lai sSYO SNn00 ssioN sawnYd aNY anon - mnaxoa rmasosia (Z)b, fZ4Yx !aSn,6YSS VI TO -ON SNn00 lan00 ZSxa 00 HOSNNOP PSTOZSOYI [AON3OK Noixis0dsIa L3noD tOAM900YT ;#X'dl SSNRAJO aNZ - 1111YSSY HOAEM Dx4usNoa (Y) (0VZ'8OLYI HIDIVI.S YI TO -ON 3DdYHO ad ASID YMOI OOZOZSOYI :713N3DY 9ZS66009 aSSSSSMY 60 ZOT060OZ at, •IIYP U01060OZ a4 asmas swix SYa 3da aria SON3SN3S TOI3SOOYt %#Xd.L NOISDIANOD HONY3W3aSIW :SSMIO 3OdYN0 0696BONOHS TZ590 tai aSYO Sano S4nY86Y (9)Z'BOLYI :334SY,LS VI ,Idn00 ,Isia 00 NOSNHOP Z d0 Z aDYd 69620600 IDU TO -ON LNnoo PSTOZSOYI IAONSDY NOIsiSOdata J.3n00 b/6 'd OE60'ON u01}ee1lsaAUj lEBimiiD 10 Aid Wd8Z:Zl 9101 '81 2n 10WA00T SMA 'CUSTOMER • • • Office of Driver services PO BOX 9204 1 Des ..6-204 Phone: 515-244-9124 18OD-532-1121oinesI Fax:i51505-239-19837 wwvciowadct.gnv Certificate Specifics Medical Examiner First Name _ Explanations -.._. - _ _. .-. ._..___ _.. medical Examiner last Name .. . . .... .....__ Rashonda _. Metllcal Examiner License Number �`_"" "" 1Colilns - -- - - - e Ical Examiner National Re 217 st Number ' ` _185001983 _._..—_ _ ._ ..__ . __ _ Metllcal Ezaminer ]unsdlcUon '6141784199 --__-_. __ e lol Ezaminer Phone -__-._ IL - -- - dedlcal Examiner Type .__�..._,i?08915-8400 _._.__. --....._.. 1etlical Certlflcate Restriction 1 —' "--""""_" Osteopathic Doctor-- __ __.._.__- .__._.___. 1edlcal Certificate Issued Date --+" ` '-- ---- - Weadng corrective lenses e ical Certificate Expiretlon Date � —"-'" -' '06/27/2016 - -- - - late Added t0 CDL75 Driving Record � - _' .. 106/278018 107/22/2036 ._ ..._ . , History Information Convictions Citation DIto 06/29/2007 -_- Conviction Date -'' -_._. .._... Certified Abstract of Driving Record Explanation Inquiry Date: 7/29/2016 10/17/2007 _ __ACD -' '-`--- 1A20 - --- .- ._ - _ IOpemnn9 Wh11¢ 1nb,Xlcated ---- _. county - --- ' _ ,. _ .. Customer #: 4342223 DL/ID #; 295DD4770 (IA) CDL Permit Class: ._.. _Johnson � .. Name: House, Antonio Maurice Class: Audit #: A CDL Permit "ue Date: A 07/22/203fi Address; 08/18/2014 1171999 CDL Permit Expiration 01/17/2017 . IA 911 HIGHWAY 1 W APT 3 Issue Date: Date: -_ Black Hawk - _ IA Expiration Date: 07/22/2016 CDL Permit Endorsements: PS IIA Operating While Intoxicated Test Refusal/Test Failure Violations 07/03/2018 CDL Permit Restrictions: Corrective Lenses, No Class A City/State; IOWA CITY, IA 922964206 Passenger Vehicle, No Passenge Mailing Address: 411 HIGHWAY 1 W APT 3ID Endorsements: NONE Status: CMV Bus None Restrictions: Commercial Learner Permit, DL Status: corrective Lenses VAL MailingRestriction IOWA CITY, IA 522464205 Supplement: NoneCity/St CDL Status: VAL Dot.Bi Date o! Birth: 7/3/1979 CDL Permit Status: LIC Sex: M COL Cert Status: Non -Excepted Interstate CDL Med Status: Certified CDL Medical Examiner's Certificate Certificate Specifics Medical Examiner First Name _ Explanations -.._. - _ _. .-. ._..___ _.. medical Examiner last Name .. . . .... .....__ Rashonda _. Metllcal Examiner License Number �`_"" "" 1Colilns - -- - - - e Ical Examiner National Re 217 st Number ' ` _185001983 _._..—_ _ ._ ..__ . __ _ Metllcal Ezaminer ]unsdlcUon '6141784199 --__-_. __ e lol Ezaminer Phone -__-._ IL - -- - dedlcal Examiner Type .__�..._,i?08915-8400 _._.__. --....._.. 1etlical Certlflcate Restriction 1 —' "--""""_" Osteopathic Doctor-- __ __.._.__- .__._.___. 1edlcal Certificate Issued Date --+" ` '-- ---- - Weadng corrective lenses e ical Certificate Expiretlon Date � —"-'" -' '06/27/2016 - -- - - late Added t0 CDL75 Driving Record � - _' .. 106/278018 107/22/2036 ._ ..._ . , History Information Convictions Citation DIto 06/29/2007 -_- Conviction Date -'' -_._. .._... Explanation 10/17/2007 _ __ACD -' '-`--- 1A20 - --- .- ._ - _ IOpemnn9 Wh11¢ 1nb,Xlcated ---- _. county - --- ' _ ,. _ .. ]UR 09/13/2D32 ___ .. - .. _.. '10/10/2012 .___592 _ '- .. _ SPeed � ___... : __ ._.. _Johnson � .. ZA _ 01/18/2014 ._._.. ._.�.__._ 02/06/2014 �M34 - _ ' T592 Fall to_O_he Traffic Sign/Signal Y _.._ -- ._.... _ i5mtt "" - -- "Johnson IA 08/18/2014 ...______2.. 5 Bed .. ...._ _. - � „ . IA ;09/28/2014 __._. __, __ ilmPmper Registration--------'_ -_ Black Hawk - _ IA ;Johnson IIA Operating While Intoxicated Test Refusal/Test Failure Violations ACD Al2 J - Sanctions Type Effective 0.evoked- 7..___._.._.____._.-�. 107/06/2007 .i Name: House, Antonio Maurice PL/ID: 255D04770 JUR IA Explanation Occurrence JUR _.. -._.. .___ _._. _. ._..__—.._..___... JUR r�OWl Test Refusal '-' "- "- -' , _....., .. ...... IA Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the custodlan of the records held by th Office of Driver services, accurate ices, that this Is a [rue and copy o/ on Transportation to recertify, official record currently In the custody of Bald office, and that I have been authorized by the Director of the Iowa Department, 101^I^ ,v2l1 II IIIY 7/29/2016 ' O Office of Driver Servlces Iowa Department of Transportation Name: House, Antonio Maurice Dl/ID; 255DD4770