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Home My WebLink About16-234� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319)3S6-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. 11y— Z.3 q (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 First Middle w 'I- 3. Contact Information (REQUIRED) Email: (All written communication sen -TM email) =f< S2firAD 3r9 -930 -g2-z4 4a. Driver's License expiration date (REQUIRED) 11" 1-1 - 1 tP b. Taxicab Business Name (REQUIRED) y 2 -L -t. o Ft d IV- '=0 5. Prior experience in transportation of passengers: r5 co, - CXAs A- ASS1S+t-.,t t`,k _ $C-✓ 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?AJ6 Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? �{iS Type of offense Where When �� prr c Bac 4 i�� `iDhnsrnl C� celq ltZ_ W hat happened to the chargee? (Qrcle one) Convicted J Dismissed Deferred Suspended Plead Guilty Other'. q1 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N a Type of offense Where When N cD 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please proVt a the name(s) - - DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIEq DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number I-LS2- `15"7 v-1 issued on lot Q I i V xpiring on It - i-1 - t W . I understand that if I falsely answer any questions in this application, that this application may be denied. I agree that in making this application, I consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and documents relating to this application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Jou A r, VA ".,I k_ on this ($ day of !'l. 0 n1.. n % 7 lit . 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 Signature of Police Chief nee g2/4 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. Signattim of City Clerk or designee ,ez ZL-.;r z// ate Office Use Only co Approved application DCl report _ State certified driving record w ..J Website update OeM/rAXIDRNMDGFAPPL92014a ded DOC 07/2016 100cf.11. 201619:_51 AM Cab U.V of Criminal Investigation (FAx)3193382Ni- 4978 STATE OF IOWA CheckCriminal HistoryRecord Request Form To: Iowa Division ofCrlminal lnvestlgatlon Support Operations Duraa% 1't Floor 215 L.7° Street Das Molnes, Iowa 50319 (515)725-6066 „ (515)'725-6080 Fax I am reouestine an Iowa Criminal Rlttn" Rarnrri Chanlr A>, - P' 1-303/003 DCl Account Number: 9967-F — (Ireppucabiq From: Yellow Cab of Iowa Clry P.O. Sox 428 Iowa City, IA. 52244 (319) 338.9777 Phone: Pox: (319) 339-7302 LAO..Name amdatoty)st Name (mandato ) - Middle Name uoeominandad Date of Birth mandato Gender (mandato 'Soviol. Security Number rewmmended) LIMAN ffFemale LAgy-O(O-9S1I0 Walvar Infoxmation: without a signed walv6orrom the subject of the request, a oomplgto grlminal history record may not be ralesaable, perCDda;of Iowa, Chapter 692.2,Bor cont plote criminal hittory•racord Informatlon, eA allowed by lew, always obtain a waiver sl nature from the sub ect of the ra upst, Waiver Release: I hcrcby aWe permtelloater tha above requoaltng omdal to eonduel m Iowa otlminal history record check with the Division otCrimind Invenlplion (DCO. My eflminal history dale wa min6 me IAat Is malnuined by the DCI ntay bo ealeated u allowed by naw. Waiver Signature: 1 Iowa Criminal History Record Check Results As of (CW WJi a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record atlaohed, DCi 9 DCI initials DCI -77 (08/25/10) Received Time Oct. 7. 2016 7:19AM No 5628 (DCI use only) -A_ Iowa Department of Transportation pp Office d paver Services (Toll Free) MD -632 1121 PO Box 034, Des MMOS, LA 51130"204 515-244-9124 4" fA)C 515-2391837 Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 10/10/2016 DL/ID #: 432YY5707 (IA) Customer #: 3875157 Name: Prymek, Donna Class: D ID Status: None Marie Address: 2175 KOUNTRY LN Audit #: 9434686 DL Status: VAL SE APT 1 Issue Date: 09/19/2015 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 09/23/2020 CDL Cert Status: None 522409302 Endorsements: 3 CDL Med Status: None Mailing Address: 2175 KOUNTRY LN Restrictions: Corrective Lenses Restriction None SE APT 1 Supplement: Date of Birth: 9/23/1979 Mailing IOWA CITY, IA sex: F City/State: 522409302 History Information Convictions Citation Date Conviction Date ACD Explanation lCounty ]UR 06/04/2012 06/19/2012 N82 Improper Backing Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number ]UR 06/04/2012 688631 IA Name: Prymek, Donna Marie DL/ID: 432YY5707 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 arweccurate copy of an official record currently in the custody of said Office, and that I have been authorized by the Director of thRwa D€0 iment of Transportation to so certify. --i CD In witness whereof, I have caused my signature and the seal of the Department to be set upon this7f; ygTent, 3t Ankjr0V Iowa this date: r,0 10/10/2016 D. 0. yyp�' Office of Driver Services aawweeee�� Iowa Department of Transporation Name: Prymek, Donna Marie DL/ID: 432YY5707 ry :.a �n cm