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Home My WebLink About16-205Ilia CITY CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB 1 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 Irk vA // i L; Middle Yl �s5 L%s�� L 3. Contact Information (REQUIRED) Email: A Ket 47y 0 &A1b 1- `— Cell Phone: �5z (All writtbn communication sent via email) 4a. Driver's License expiration date (REQUIRED) 10 `)- �, —a, 0,� d b. Taxicab Business Name (REQUIRED) �0110 W (fib 10 Wr9 5. Prior experience in transportation of passengers: yes 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When Se�fd {N IV, 0 IA T(I QN 1 %/i �olS 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 What happened to the charge? (Circle one) Where When 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? fvp 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 the name(s) Ik) 0 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 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number yds _r,�S�`/ issued on 1 expiring on 10 -,Zi -2O,7,0. I understand that if 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 /Z, L ri (.4,— Date 6 – li - oS�� STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by W C,9A_M_bQ Pry( 12 on this k2 day of 219. 1 ^ / %1 \YA_l d/ i � I I� L 1 in Md for the 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 /OS !-,7- g1/4/1-6 Signature of Police Chief 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. Signhture of City Clerk or designee Y Office Office Use Only Approved application DCI report State certified driving record Website update OerffAXIDRIVBADGEAPPL92014a ded.DOC 07/2016 /Date OerffAXIDRIVBADGEAPPL92014a ded.DOC 07/2016 DyrSep.A. 201634:,30PMcabDiv of Criminal Investigation (FAX)3t93382No.3012 STATE OF IOWA Criminal History Record Check ,,'�1t�,�;;+mss: �'R4r,ri'+' Request Form Tot Iowa Division orCrimlaal Investigation Support 0pert tionsAlurep a, 1't'Floor 215 E. 7'a Street Des Moines, Iowa 50319 (515) 725.6066 (515)'725.6080 Fax Iowa P. 1 /2,/002 DCI Account Number; 9967-F (Ihppileable) From: _ Yellow Cab_of Iowa _Clry P.O. Box 428 ' Iowa City, IA. 52244 (319) 338.9777 Phonal Fext (319)339.7362 "'•'��•'�'nI rtrac &Name mandatory) Mldd10"N 030 (recommended)' Pee /] Qaic� -_- %�/4�4 P1 l ae,Ad mr9a' a ❑Fetnale Sad if Waiverlr(farnlaffatf; Without a signed waiver from the subject of the regpest, a eomplgta griminal history record may not be releasable, per Code Drlown, Chapter 692.2. For complote criminal history -record Informallon, as allowed by law, always' WQIYOr Release; I heroby give pmmltrion for the abovd rdquaang osncial to conduct m Iowa criminal hbtotyrcoord cheek with the Divhion di'Crlminal Invcsilt ellon (DCO. Any ctlminal hlstory data concerning melhat b mt(ntained by the DC1 nley be reisased u allowed by low. Waiver Signature, I Nva CriminsI History Record-Chosak Results (oCluse only) AS of `� bio a toarch of the provided name and dato of birth ravealcd; f No Iowa Criminal history Record found with DCI 1 F Q Iowa Criminal History Record attached, DCI # 17Cl initials �. DC1•77 (08/25/10) Received Time Sep. 8. 2016 9:44AM No.3515 Q00OUVADOT www, owadot.gou SMARTER I SIMPLER 1 CUSTOMER DRIVEN Office of Driver Services PO Box 9204 1 Des Moines, [A 50306-92114 Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837 www.iowadot.gov Inquiry 8/18/2016 Date: Customer 1200814 Name: Price, Michael Roger Address: 119 LINN ST City/State: ATALISSA, IA 527207738 Mailing PO BOX 43 Address: Mailing ATALISSA, IA City/State: 527200043 Date of 10/28/1956 Birth: None Sex: M Certified Abstract of Driving Record DL/ID #: 428XX5204 (IA) CDL Permit Class: B Class: A Audit #: 9732911 Issue Date: 01/26/2016 Expiration 10/28/2020 Date: Endorsements: N Restrictions: Commercial Learner Expiration Date: Permit, Corrective CDL Permit Lenses Restriction None Supplement: Corrective Lenses, No CDL Medical Examiner's Certificate CDL Permit Issue 02/18/2016 Date: CDL Permit 07/23/2016 Expiration Date: _ Oustin CDL Permit PS Endorsements: ` CDL Permit Corrective Lenses, No Restrictions: Class A Passenger _Number _ Medical Examiner Jurisdiction \ Vehicle, No Passengers Medical Examiner Phone in CMV Bus ID Status: None DL Status: VAL CDL Status: VAL CDL Permit ELG Status: CDL Cert Status: Non -Excepted Interstate CDL Med Status: Certified Certificate Specifics Explanations Medical Examiner First Name _ Oustin Medical Examiner Middle Name 'Robert Medical Examiner Last Name Seifert Medical Examiner License Number _ 007287 Medical Examiner National Registry 6795309930 i _Number _ Medical Examiner Jurisdiction \ JA Medical Examiner Phone '(563) 468-5512 Medical Examiner Type _ _ _ - ,Chiropractor _ Medical Certificate Restriction 1 ;Wearing corrective lenses _.. ... ._ _.. .ri _____. Medical Certificate Issued Date _ _ _ i _ ._ ._ 107/07/2015 Medical Certificate Expiration Date _ _ 07/07/2017 Date Added to CDLIS Driving Record j01/26/2016 History Information Convictions Citation Date Conviction Date _ ACD _ Explanation County JUR D3/20/2015 '.04/23/2015 i ;Miscellaneous (Muscatine rIA Name: Price, Michael Roger DL/ID: 428XX5204 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 antl the seal of the Department to be set upon this document, at Ankeny, Iowa this date: '•y.�'EP y 8/18/2016 IOWA D. 0. T.: W, �F OBNER $�Q Office of Driver Services Iowa Department of Transportation Name: Price, Michael Roger DL/ID: 428XX5204