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Home My WebLink About16-253®iliJ� �_ CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) 3. Contact Information (R IDENTIFICATION NO. )(a _�5:3 (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 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQU 5. Prior experience in transportation of passengers: 3/2/Z 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When W nat happened to the Charge-? (Circle one) L t � L Convicted Dismissed Deferred Suspend Plead Gull Other Have you been arrested / charged with any traffic offenses in the last five years? �fi What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead GuiltyOth ._ e&..�{ ) tidgPNp+ i 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Nb Type of offense Where ".men - c 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the' name( -4 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'Jcl (A LA 5917 issued on 09/Z3/7.olxpiring on 03/D2h,n7,1 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 pter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant /' I (d"�I B►^�� 1v1NN1� Date STATE OF IOWA ) COUNTY OF JOHNSON ) S bscribed d sworn to before me by 01 ' KELLIE K. FRU on this "1' � ` day of 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). l Expiration date of Driver's license h& --u �1�' Signature of Police C i� or designee 1! li�l ib Dale 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. �Oal,11114� _1A11/ ig ature of City Clerk or designee Office Use Only /A, A Prate _ 4 Approved application _ .J v. DCI report t7- --- State certified driving record Website update ~ c.n .. o Oer TAXIDRN&4DCEAPPL92016am ded DOC 07r2016 YV v, y• LV IU L•7VI III VII VI VI IInl Ilei 11. cal 1t.el IVa iIV. I IVJ I/ 1 F, _..,,,.,, ,� •„ .O b.. ...,� Cl o,� waiver'Release; I hereby give permission for dm above requesting official to emntuel an Iowa criminai history record cheek qid1 the Division ofcriminal investigation(DCI). Any criminal history data concerning me that is rnsinlained by the DC] may be released as allow ed by le w•, Waiver Sigmattere; a73b r.w2/002 STATE O. IOWA q Criminal tt Check Request tGO", rin i ../ To! lotva Division of Criminal Investigation Support Operations nnrean, I" Floor 215 E. 7"' Street Des Motiles, Iowa 50319 (515) 725-6066 ($15)725.6080 Fax I ani renueRtino An YnVVa f'rin.inal iriMn,•.. Bw,....•A r U..L — . DCI Accounl Number: I -q 01:7) 7 (ifapplicabic) From: City 0f Iowa City City Cleric's office 410.E. washingfon Street Iowa City, IA 52240 Phone: 319-356.5041 _ Fax: 319-356-5497 Last Name (mandatory) First Name emondaloiy) Middle Name occon, vended) of Birth (maneaioy) Gende (Inanda ry Social Security Number (recemmnsaea) /Date U?j ' g ®Male �Fcmale 4 5 77 Waiver Information: Without a signed waiver from tho sub)cct of the request, a complete criminal history record may not be releasable per Codd of Iowa, Chaplet 692,2. For eo etc erlminal hlstory record information, as allowed by law, always obtain a waiver si nature from the sub act of the request, waiver'Release; I hereby give permission for dm above requesting official to emntuel an Iowa criminai history record cheek qid1 the Division ofcriminal investigation(DCI). Any criminal history data concerning me that is rnsinlained by the DC] may be released as allow ed by le w•, Waiver Sigmattere; v Iowa Criminal History Record Cheek Results (D(7I lire only) As of a__/�(� _, a search of the provided name and date of Will revealed; No Iowa Crinunal History Record found with 17CI ❑ Iowa Criminal History Record attached, DCT # w DCI initials x DCI -77 (08/25/10) Received Time Nov. 4. 2016 9:54AM No, 6804 Page 1 of 2 C1J10WAoaT www.iowadotgnv .- - SMARTER I SIMPLER I CUSTOMER1 RIVEN Office of Driver Services PO Box 92041 Des Moines, U150306-9204 Phone: 515-244-9124 1800-532-11211 Far .515239-1837 www.iowadot-gpv Inquiry Date: Customer Name: 11/1/2016 1798490 Certified Abstract of Driving Record DL/ID #: 334UU5927 (IA) CDL Permit Class: None Class: D Fominyen, Muyang Boni Audit #: 9445038 Address: 128 E BLOOMINGTON ST Issue Date: 09/23/2015 APT 1 Expiration 03/02/2021 Date: City/State: IOWA CITY, IA Endorsements: 3 Convictions CDL Permit Issue None Date: CDL Permit 522456205 Mailing 128 E BLOOMINGTON ST Restrictions: Address: APT 1 Restriction Mailing IOWA CITY, IA Supplement: City/State: 522456205 Date of 3/2/1984 Birth: VAL Sex: F Convictions CDL Permit Issue None Date: CDL Permit None Expiration Date: Explanation CDL Permit None Endorsements: 04/03/2007 CDL Permit None Restrictions: IA ID Status: VAL NONE DL Status: VAL None CDL Status: None CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County ]UR _01/06/2007 04/03/2007 S92 Speed Iowa IA 06/12/2016 08/26/2016 M14 Fail to Obey Traffic Sign/Signal Johnson IA Sanctions Type Effective End ACD Explanation Occurrence JUR ]UR Suspended 05/28/2007 11/03/2007 IS92 ISerious Violation IIA IIA Name: Fominyen, Muyang Boni DL/ID: 334UU5927 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: 11/1/2016 11/1/2016 Office of Driver Services Iowa Department of Transportation Name: Fominyen, Muyang Boni DL/ID: 334UU5927 Page 2 of 2 11/1/2016