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Home My WebLink About16-218� r 1 it""III�� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319)356-5040 (319)356-5497 FAX Name (REQUIRED) IDENTIFICATION NO. /I o— 7—fp_ (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 m 2. Address (REQUIRED) 1U(, U SC o rr PAek- ae pq l y- da (t 3. Contact Information (REQUIRED) Email: e, m k/p *C 5* 'd Q qMa• ) . C. m Cell Phone: 3/S'- Ga (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) h- ) 3- � v J Y b. Taxicab Business Name (REQUIRED) YC` 110N Cu 6 5. Prior experience in transportation of passengers: W oR k'cc d ro R YC I l0W C /9 b y Y4! it A dei 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /UJ Type of offense Where 6 - a �I Cl CAICA.,o What happened to the charge? (Circle one) Convicted Dismissed When Ail Deferred Suspended Plead G ' Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When _ *V A-12- arrlfc &C: Q&AJ nv Pa.wi s iJIS C,.R r j JA C -h jA 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? Type of offense /A 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) 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) C' 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that f1I ppave issued to me by the Iowa Department of Transportation a valid Driver's license number d QC 3 ix)fJ (o(o5N issued on lolaoJ3 expiring on /0-/3 -.2,A) 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 q' STATE OF IOWA ) COUNTY OF JOHNSON ) 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 16 - / 3' a d% V Stix Signature of Police Chief or designee �24�§��4 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. Signature of City Clerk or designee 9/,2 g-/�1G T e+eeeeeeeerereeererereeeee»reareeerexe+eeeeaeeaeereareeeree+eeeeeererarrreereereerxeereereerreeeeexeeeeereeereeaeree+rereeeeree+r+er+ea+arereee Office Use Only Approved application DCI report State certified driving record Website update Bleddr"IDRNBADGE PPLszbiaamended.Doc 072016 13TATE OF IOWA �• z, ` Criminal History Record, Check .a Regleest Form To; lora Diviolon of Criminal Investigation Support operations Bureau,'I" Floor 21511, 7'h Strcet Des Moines, Towa 50319 (515) 725-6066 (515)725-6080 Fax 1 am reateslina nn lnmva Criminal AiNnly ttarnrd Phar, nn• ..alio . ._�cruuc L � DCl Account Number: +6W _F -- (ifapplietole)— From: City of Towa City City Clcrlt's office 410 T:. Washington Sheet Iowa City, IA 52240 Phone: 319-3S6-5041 Fax: 319.356 -5497 -- Last Name (n,anaslery) First N21ne (mendalory) Middle Name (,cwmmcnded) to erg 0M0 Date of Birth (mandatory) Gender (mandatory) Social Security Number recommended) p.G :13 l rj S `d ®Male ®Femala 'WId -1-7 /1 . Waiver Infomiafioi : Without a signed waiver from the subject of the request, a c6inpleto criminal history retard may not be releasable, per Code ol`Tow•a, Chapter 692.Z. ror complete crlininal history record information, as allowed by.law, always obtain a waiver sienature.fran the sub eet of the request. Waive7ReMO$e:Iherebygive yemiission(of rbeoboverequestinaofficial to conduct inlowhetimivalhistory rccorddicekwith the Division ofCriminal ' Invcsligation (nCI), pay criminal history dnlaconeeming me that is mainlaiucd by IhcpCl maybe released as snowed bylaw. WniverSignulure: >� lowra Criminal History Record Check Results MCI list only) As of b , a search of the provided name and date of birth revealed: ❑ No Iowa Cruninal History Record found with DCI Iowa Criminal History Record attached, DCI t! f" w t DCI initials �r DCI -77 (08/25/10) — -- — -- Received Time Sep, 23, 2016 7:57AM No. 4641 JCP. LV, LVIV J - V II III u I v u1 v iiia 1 115 1 +ov va, 155, 1v11 :" IOWA CRIMINAL HISTORY DCI 00378167 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED - 2016/09/26 DCI:00378167 NAME: KLOPFENSTRIN, KIM LER DOB $E% RAC HOT WGT EYE HAIR Sm POE 19581013 M W 511 185 BRO ELK IA ADDITIONAL IDENTIFIERS CCH RECORD •r• 01 ARRESTED 19880807 AGENCY: IA0920000 WASHINGTON CO SO CHARGE NO- 01 IA STATUTE IA123-47 SUPPLY BSER -MINORS TRK#: L34552201 COURT DISPOSITION AGENCY: IA092015J WASHINGTON CO DIST COURT COUNT NO- 01 IA STATUTE: IA123-47 AIDING E ABETTING CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 04552201 SENTENCE DISP EFF DAT FINE $100 19860819 02 ARRESTED 19910624 AGENCY: iA0920000 WASHINGTON CO SO CHARGE NO- 01 IA STATUTE IA321A-32 DRIVING U/SUSPENSION TRK#: L34552301 COURT DISPOSITION AGENCY: IA092015J WASHINGTON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321A-32 OPERATING WITHOUT LICENSE CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L14552301 SENTENCE DISP EFF DAT FINE $15 19920204 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 iv v. ,r v, .. ,. C4J10WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWBdOt.gOV Office of Driver Services PO Box 9204 1 Des Mo€nes, IA 50306-9204 Phone: 515-244-9124 1800-632-1121 1 Fax: 515-239-1837 www.loviadol.gov Inquiry Date: Customer Name: 9/13/2016 3212193 Certified Abstract of Driving Record DL/ID #: 263AD6654 (IA) CDL Permit Class: None Class: D Klopfenstein, Kim Lee Audit #: 7391762 Address: 720 5TH AVE City/State: CORALVILLE, IA Convictions Issue Date: 10/01/2013 Expiration 10/13/2018 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit 522412010 Mailing 720 STH AVE Address: None Mailing CORALVILLE, IA City/State: 522412010 Date of 10/13/1958 Birth: None Sex: M Convictions Issue Date: 10/01/2013 Expiration 10/13/2018 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit CDL Permit None Restrictions: ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Status: CDL Cert Status: None History Information CDL Med Status: None Citation Date Conviction Date ACD Explanation County )UR )9/08/2014 10/08/2014 M16 Fail to Obey Traffic Sign/Signal IL Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Occident Date Case Number JUR )2/12/2016 907483 IA Name: Klopfenstein, Kim Lee DL/ID: 263AD6654 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: ..y" a—�Q�ENICIf,p�G;!ie 9/13/2016 Office of Driver Services Iowa Department of Transportation Name: Klopfenstein, Kim Lee DL/ID: 263AD6654