HomeMy WebLinkAbout16-250� l 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-SO40
(3 19) 356-5497 FAX
Name (REQUIRED)
IDENTIFICATION NO. )p 2 -SO
(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
Middles
Last
2. Address (REQUIRED)
3. Contact Information (F
4a. Driver's License expiration date (REQUIRED) 10 I 1 a) %0 I
b. Taxicab Business Name (REQUIRED) V1 S 2 Y, I
5. Prior experience in transportation of passengers:
L4 CAP. o, r�-. 1� 11�
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years?
Where
What happened to the charge? (Circle one)
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
AAl',,_,
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 12J
Type of offense Where Vtihen Mg.•�
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide'them
IU o ro
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 certfy that I have issued to me by the Iowa Department of Transportation valid Driver's license number
y 3I xx 7�] 3 issued on OL3expiring on 1. I understand that if I
falsely answer any questions in this application, that this application may be denied. 1 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 I�g c�C'!.y2 Date W7 � (Co
1HH\YffHff!lflYYYll1H1H}1N1HflHHll111HHlffffYHHHH+1f 11H1HfH1!lHfHYY„kiYHYHY4iHYlH11f lHilRlYfHfl1MHYHHH\Hfi-ff 11H
STATE OF IOWA )
COUNTY OF JOHNSON )
S scribed a d sworn to before me by / �_<0 /,e r on this day of
CC (i r� � ” LLQ !t✓LL-
r� 4 KELLIE K. FRUEHLING Notary Public in and fof the State of Iowa
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 Q"f Iowa City (Title 5, Chapter 2, City Code).
date of Iver' license
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.
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
11Z7
0
Date
71
Clerk MIDRN94DGEAPPL92014emen .DOC 07/2016
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Clerk MIDRN94DGEAPPL92014emen .DOC 07/2016
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ep
Div of Criminal Investigation .001 TOYi,°'oo�u r•��04
STATE OF IOWA
vM
Criminal History Record Check
Request Form,
TO, Iawa DIVISION of Crlm)NN1lovatilp ffoo '
support Operutlons Bureau, 10 Floor
216L76Shut
Dee Malna,IMM 50319
(515) 7254080 Far
DO Account Number V - C
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MetNNme FirvtNNme
Middle Name mantanefed)
}Cob es rz.
Date of Hlrt4 GenderBoclal
secatcit Number
Owe emale
`kb " oU - I G as
R'dlver lnjormatlorl: Wlthost a elgned watvry ttom Of WNW of the regret, a complete crIMINal b1nory record may not
Iowa, Chapter 6973. For colli trINSIgsl h4toryreeord Informalloa, as allowed by law, altwys
ha rel=raW per CWc of
■ wataer a stare from the ab edof the Nat.
WUtW? ReleaSe: 1 bmby prr ps ieien rQ the abow nqualer OMW m wadmiM1OWS dmhY hkbq rotayd eldc with do eirldm 00MIng
rnrdlpubeloClL uryrdmind hlrtaydat molal nahabW by aeeClrartc mltsed a Rowed by 11W.WdfverSgndfrtre:
(rcr=only)
As of 11-14(o a search of the provided name and date of blab revealed.
fi
No Iowa Criminal History Record found with DCI
Iowa Criminal History Record atlechcd, DC10 .11
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DCl initlais ,
Received Time Oct. 26. 2016 11:02AM No. 6627
Iowa Department of Transportation
Oftm CE ON d Diner CorAce's (Tali r -me) ! -532.1121
PO Box 9204. Ulm tAwws, Is 503WOM 515.244.8124
FAX 515.2351831
History Information
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
10/25/2016
DL/ID #:
431XX7973 (IA)
Customer #:
4283012
Name:
Kober, Tara Ashlee
Class:
D
ID Status:
None
Address:
804 BENTON DR
Audit #:
7292821
OL Status:
VAL
Speed
APT 14
IA
07/30/2016
08/23/2016
B64
I No Insurance Card
Johnson
Issue Date:
08/29/2013
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
10/12/2018
CDL Cert Status:
None
522465204
Endorsements:
3
CDL Med Status:
None
Mailing Address:
804 BENTON DR
Restrictions:
NONE
Restriction
None
APT 14
Supplement:
Date of Birth:
10/12/1985
Mailing
IOWA CITY, IA
Sex:
F
City/State:
522465204
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
3UR
09/20/2009
10/09/2009
M14
Fail to Obey Traffic
Sign/Signal
Johnson
IA
12/11/2009
12/28/2009
M14
Fail to Obey Traffic
Sign/Signal
Johnson
IA
01/15/2D15
02/11/2015
S92
Speed
Johnson
IA
07/30/2016
08/23/2016
B64
I No Insurance Card
Johnson
IIA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
IUR
11/03/2013
765122
IA
07/03/2014
807943
IA
03/2712016
913710
IA
07/30/2016
933890
IA
Name: Kober, Tara Ashlee DL/ID: 431XX7973
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:
10/25/2016
IOWA jya�4oe;�epe
D. 0. T.
Office of Driver Services
Iowa Department of Transporation
Name: Kober, Tara Ashlee DL/ID: 431XX7973