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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
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
Last
2. Address (REQUIRED) %9L;)- \�6k\, ('k
3. Contact Information (REQUIRED) Email: Ynv _Qnol_ Ct.lotv/G�ynhoo ca Cell Phone: i12- ;ll- ZS 1k
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) oq - A7 - olp at
b. Taxicab Business Name (REQUIRED) Ye how Cab nt owa C,4111
5. Prior experience in transportation of passengers: Sr.1 m1 \cv< CL"aw- , kr0-4rnwc E
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Vo
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? k/0
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? AQ
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)
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
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
3�M f03O issued on o4 -aur; expiring on 69-a7 ar . 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, C ppter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Y/ Date/o- S /Ci
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STATE OF IOWA )
COUNTY OF JOHNSON ) p
Subscribed and sworn to before me by Con this day of
in and for the
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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 C71ity of Iowa City (Title 5, Chapter 2, City Code).
D
or designee D to
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
10 -6_ 1t<
Date
f}}ff+rfllrlfmmlrfmm}fmrf+lf:rfrfffrrfrf+raa+rrrrrfrrrffrrfrlrrrrfrrrfrfrrrffrffrffffrrrrrrrrrf«frrrfrffrrrrrfrrfr:rrf:rffrrffefrrrrf
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CIeARA%IDRIVBADGEAPPL92014amwOO.DOC 07/2016
09/0ct. 3. 20163 4:35PMcapDiv of Criminal Investigation (FAX)3793382;No.4346
STATE OF •
tl� tlli'�aj �1Criminal History Record
e e
Request Vorm
AI
Tot rewa Division of Criminal Investigation
Support Operstlons Bureau, I" Floor
215 E. 7'" Street
DesMolnet,fowa 5031➢
(515) 7256066
(515) 725,6080 Fnx
I am reouestino en MMA rrlminal [7(.r.,.., 17 --- .Aa h..L
P. 1/1/DD2
DCT Account Number:—9967•F
(Ifeddlleebta)
From; XelloW Cab of Iowa City
F.O, box 428
Iowa City, IA. 52244
(319) 338.9777
Phone)
Faxt (319)339-7302
Last Name maneud
First Name mandato
Middle Name haeammenao4
au
Date of birth fmmd.t.yl.
Gender (mandato)
Se lal-SecuYl Number recommends
O -0 - 1"M
_M/Male ❑Female
Waiver Information: Without a signed waiver from the subject of the rogvost, a compiote Criminal history record may no
be releasabtc, per Code of fo,we, Chapter 692.2. For complete criminal history -record Information, ail allowed by low, always
obtain a waiver signature frobi the sub set of the request.
Wa&Cr RCIMSe: I hereby glve permission for the ab ve requuting oftlal 1 to oonduci m Iowa criminet h1vory record check with the Division of Crlminel
Invoulsatlon (DCq, My odminol history data cooeemin a that Is I Ina by t>C maybe seleesed as allowed by low.
TYatver Signaluret
(DCI va• only)
As of [Q (� a search of the provided name and date of birth revealedc
No Iowa Criminal history Record found with DCI
❑ Iowa Criminal History Record attached, DCI # _ ti
DCT initials �
DCI -77 (08/25/10)
Received Time Sep, 29. 2016 12:52PM No, 4142
ARTS Page 1 of 2
C1410"WADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN
vvvvw,iowadot.gov
Inquiry
Date:
Customer
Name:
Address:
9/29/2016
6550751
Ceber, Jean Paul
Office of Driver Services
PO Box 9204 1 Des Moines. to 50306-9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
DL/ID #: 132AM6030 (IA) CDL Permit Class: None
Class: B
Audit #: 1326030
1822 HOLLYWOOD CT Issue Date: 09/27/2016
City/State: IOWA CITY, IA
522405931
Mailing 1822 HOLLYWOOD CT
Address:
Mailing
IOWA CITY, IA
City/State:
522405931
Date of
9/7/1991
Birth:
Office of Driver Services
Sex:
M
Expiration
09/07/2021
Date:
Endorsements: PS
Restrictions:
CDL Intrastate Only, No
Office of Driver Services
Air Brake Equipped CMV,
None
No Class A Passenger
Vehicle
Restriction
None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Ceber, Jean Paul DL/ID: 132AM6030
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
Office of Driver Services
CDL Permit
None
Restrictions:
ID Status:
None
DL Status: VAL
CDL Status: SUR
CDL Permit ELG
Status:
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:
"""•tibio
9/29/2016
.IOWA
D. 0. T.;�
.*
f ...... e
Office of Driver Services
Iowa Department of Transportation
http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/29/2016