HomeMy WebLinkAbout16-261� r 1
CITY OF IOWA CITY
410 East Washington Streel
Iowa City, Iowa 52240-1826
(319)356-5040
(319)356-S497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. - Z
(Office Use nly)
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
prcZ
Middle
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C,
C, —H -rlq ! 7214
3. Contact Information (REQUIRED) Email: btG Am tr @j 4#12. & 6 046,1.- Cell Phone:319 - 936 -207
(All written communication sent via email)
4a. Driver's License expiration date (REQUI
12 -27 -Zola
b. Taxicab Business Name (REQUIRED) V v tPa WS5/I
5. Prior experience in transportation of passengers: % `�c�+-S f v 1JXzQ2`- `
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? NO
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other t� -
7. Have you been arrested / charged with any traffic offenses in the last five years? N G
Type of offense Where When
59rtio I 1-,0I -zao5
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? h) 0
Type of offense Where When
0
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro 0' tlfqhame(gj)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIII IED IT
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE.C_F 1EW^-n
You must apply for an individual Department of Criminal Investigation Report (form available ur bn 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 a valid Driver's license number
3 26 f -)-L- issued on 0 -10 - I \ expiring on 12 ^ 2"7 -ZO . I understand that ff 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, off the City
Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant �'� 6 Date 1-2- '/_0 ZOO b
fYYH11f11114+#ifii}}},HIHH}f HlH1H!}fi+11HH1H1H1fYffillllfYf!l1flH1HfH1HfYYfYf 1f f fIYfYYHY'k1f}YH}H!f-IH}HHfIHf 11l11!!!!!!f!H
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed 1 -a_n�d- sworn to before me by ikt r��Q CA52��o�jf on this day of
1T Qt 2u4nw 7.d—Lo 11 ,,
Notary Public in a d for the State of ]Qva
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 to ity (Title 5, Chapter 2, City Code).
Expiration ate of river's ' ns ' L Z % i O
Tj
1z �-/fes
Signature of JA61ice ChTeTor 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.
%lz_f&ef,z�� K. _e�
Sign e of City Clerk or designee
..11,111Y1.HH,f1f1f1}H,HH H11,lY1Ylf,H,HHI,}M,f1i'tH.HH„H.,flfHfHlfl,fl1,f11f111fYfflYYlii}i.H
Office Use Only
Approved application
DCI report
O
State certified driving record
Website update
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perk/rAXIDRNSADGEAPPL92019amB dB .DOC
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`...✓ 07x2016
0
Page 1 of 2
C,J10WADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWadOt.gOV
Office of Driver Services
PO Box 9204 i Des Moines, IA 50306-9204
Phone_ 515-244-9124 1 8OD-532-1121 i Fax: 515-239-1837
www.iowadot.gov
Inquiry
Date:
Customer
Name:
Address:
11/30/2016
3959505
Certified Abstract of Driving Record
DL/ID #: 013BB2642(IA) CDL Permit Class: None
Class: D
Casella, Michael Peter Jr Audit #: 9563241
2110 N DUBUQUE ST Issue Date: 11/10/2015
City/State: IOWA CITY, IA
Convictions
Expiration 12/27/2020
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
522451624
Mailing
2110 N DUBUQUE ST
Address:
None
Mailing
IOWA CITY, IA
City/State:
522451624
Date of
12/27/1956
Birth:
None
Sex:
M
Convictions
Expiration 12/27/2020
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
CDL Med Status:
None
History Information
Citation Date Conviction Date ACD Explanation County JUR
11/01/2009 11/30/2009 592 Speed Johnson IA
Name: Casella, Michael Peter Jr DL/ID: 013BB2642
N
O
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa DepaGu:ent of�jrTansportation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this i9:4 true apd accur3"opy of
an official record currently in the custody of said office, and that I have been authorized by the DirectQ`iF4 oFwa Depatl[lient of
Transportation to so certify. '
In witness whereof, I have caused my signature and the seal of the Department to be set upon this3ment, at An, Iowa
this date: `rr, � I�1
C7
'VEHICLE ``a
�OtOe��b 11/30/2016
""""%* DBNtR Office of Driver Services
o Iowa Department of Transportation
11/30/2016
20160 I OO PM
n
O
Div of Criminal Investigation ., DCI IoeNo.6650 P.,los
STATE OF IOWA
Criminal History Record Check 2
Request Form
Tot Iowa Division of Criminal lavesilgatlon
Support Operations Bureau, I" Floor
215 E. 74 Street
Des Moines, Iowa 50319
(515) 7246066 - --
($IS) 72S6080 Fax
i . ..,twat . ens. rr)min.l midnn. aar.wt Chen4 no.'
DCI Account Number; 13o - PC,
Proms MAV(,5 0.)(1
116 54vt..i Or.
phone; ,(31q) 338
Fax: . 919 551
C
Lost Name tmenowtory)
First Name (nWdumy)
Middle Name tteom,nwm d)
0P(s0—�A- 2
l.I- Ck 1 L
fC7-cr?--
Dote of Birth onnstal-tyi
Gooder minae )
Social Security Number (..now)
)
`Srp
nle ❑Female
33 9. J O` y O ZZ
Waiver Information; Without a signed waiver from the subject orthe request, a complete criminal history record may not
be rsleasoble, per Code or Iowa, Chapter 692.2. For complete criminal history racord larormallon, as allowed by law, always
obtain a waiver sleasturst ftyne the subject orthe request.
Waiver Release, i henby `ivo mmusim to, Ne.hove tce.em,eg oticxt to radon, w Iowa odminal hitgry (.cold thuds with 9e Division orCrimhal
Invnaigatioll (DCI). Any rdmin.l WOW, dateOncoming me thml is meinteined W ew DCI flay be teteued u 11",lyw,
WaiverSlgnatare y-----�
As of 11- i io My, e search of the provided name and date of birth revealed:
2- No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record aftched, DCI b
DCI initials_
livi—
Received Time Oct, 26. 2016 11:02AM No -6827