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CITY OF IOWA CITY
910 East Washington Slrcet
Iowa City. Iowa 52240-1926
(319) 3S6 -S040
(319) 356-5497 FAX
IDENTIFICATION NO n-(- -zl
(Office Use Only)
APPLICATION FOR TAXICAB I 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 resuh in denial of the application
F rrst le ast
1. Name (REQUIRED)
2. Address (REQUIRED) jQ irry, Am, S -z-,;Yo `T-
3 Contact Information (REQUIRED) Email: IA- 42 ) jx, �Vta1 Phone '� 14 'SSc) � I
(All written communi'i'�tlon sent via email) f
4a. Chauffeur's License expiration date (REQUFiLDi
b. Taxicab Business Name (REQUIRE U) R
5. Prior experience in transportation of passengers:
6 Have you ever been arrested / Charged with any misdemeanors and/or felonies in this State or elsewhere?
Tvue of offense Where
_
low
2. 00�
What happened to the charge? (Circle one)
Convicted Dismissed Dfe Suspended
Plead Guilty Other
7. Have you been arrested i charged with any traffic offenses in the last five years?
TyRg ofoffense ^ Where
When
-7� ?r�l
y9 —. (I✓�� ,ter (a ar.�,4
What happened to the char e? (Circle one)
-_
Coed Dismissed Deferred Suspended
Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years?_
Where
Haveypu ever applied to be an Iowa City taxi driver using a different name?
Whnir _�
r
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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
y thtl }eve ed to me by the Iowa Department of Trensportatiop a valid Chauffeur's license number
I fi � Z� issued on 3•ZB� IS expiring on f :7 Z —7 . I understand that if I
fals ly answer a y questlons In'this application, that this application maybe 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 relatingthis application, and I furtheragree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the rjs(ons of Trtie 5, Chapter 2, of the City Code. (Needs to be signed In front of a Notary Public)
Signature ofApplicarl Date u
MINfNiiNNAIiNrtNHHHlitff fkf HKf fii4f tlfHHHN IHMf aHi#1iMNif ill+itNtM�ff sf �+MtNiiHt1KMH#14fHiKHMiifllHfkMiHllNf
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by
hu ci-A 7�1 LP
on this Z5-_ 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 (Tide 5, Chapter 2, City Code).
Expition at of uffeuesricense oi'Z��dfW/�
Signa ur of Police Chief or designee Data
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.
Sign re of City Clerk or designee
'ate
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Office Use Only
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Approved application
DCI report
State certified driving record
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03015
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Office Of Dl Ivor Services
PO Box 9204 Das Moines 1A 50306-9206
Phare. 515.244.81241800.532-1121 1 Fac. 515.239.1837
MW lawadot.gov
Certified Abstract of Driving Record
Inquiry Date: 3/15/2016 DL/ID 1r: 134000201 (IA)
Customer;V: 4544774 Class: D
Namer Mazga), Dustin Roy Audit tfr 8963357
Address: 1913 FLATIRON AVE Issue Date: 03/28/2015
Expiration Date: 01/23/2022
City/State: IOWA CITY, IA 522405961 Endorsements: 3
Halling
1913 FLATIRON AVE Restrictions: NONE
Addresen
Restrletlon None
Melling
IOWA CrrY, IA 522405961 Supplement:
City/State:
07/18/2000
Data of Birth:
1/23/1990
Sea:
M
History Information
Convictions
COL Permit Claes: None
CDL Permit Issue None
Date:
COL Permit
None
Expiration Date:
Exploration
COL Permit
None
Endorsements:
07/18/2000
CDL Parrott
None
Restrictions:
& under In 35-55 mph zone)
ID Status:
None
OLStatus:
VAL
COLStatute
None
CDL Permit Status:
ELG
COL Cert Status:
None
COL Med Status:
None
citation Date
Conviction Date
ACO
Exploration
tC%`,Q•011�1F'�
County
JUR
07/18/2000
08/27/2008
592
Speed (10 mph
& under In 35-55 mph zone)
Banton
IA
10/08/2008
10/24/2008
592
Speed C 2 mph
8. under In 35-55 mph zone)
unn
IA
12/11/2008
12/30/2008
592
Speed (10 mph
& under In 35-55 mph zone)
Linn
IA
07/28/2009
08/24/2009
542
speed (10 mph
8. under In 35-55 mph zone)
Linn
IA
06/26/2011
07/19/2011
S92
Speed (10 mph
& under In 35-55 mph zone)
Washington
IA
02/06/2013
03/18/2013
S92
Speed (10 mph
& under In 35-55 mph zone)
Iowa
IN
Name: Mazge), Dustin Roy DL/ID: 134CC8201
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certlFy'hat I
em the cusu dlan of the records held by the Office of Driver Services, that this is a turtle 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 no 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:
Name: Mazga), Dustin Roy DL/10: 134CC8201
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tC%`,Q•011�1F'�
3/15/2016
W.
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G1gLe
Office of Driver services
•dd���_
Iowa Department of Transportation :' •-
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Name: Mazga), Dustin Roy DL/10: 134CC8201
Bial. 16 L910 7:]4fie1 Uly 07 Ltl@Inal Invesllgation No. 9911 P. 2/3
PCPfn:CItY of levee City CicrK oIflea 319 3"6497 n3f K/Re1B oa:30 6AS6 P.CoWaOa
STATE OF IOWA
` Criminal ]Elistolry Remed ivfleek 11
Request Form
DCI Account Number�-
0ramUmble)
To: Iowa Division of Criminallnvestfgatlon From: City of Iowa City _
Support Operatiuos Bureau, I" Moor City Clerk's Office
net re 71" Street 410.C. Washington Shia!
DesMulnrs,loWA $0319
(SW 725.6066 low City, AA. 52240
(SIS; 925.6000 Far
Fitoae•. 319.3565641
Foe: 319-3915-5497
1 nm MUUt nfine an Itnva bi,,.inat i-6etnru V.IM I Ph.dr ..,,.
Last Name (manovery)
(ilizodsia7l117IddlelValge
lemmnelded)
A
Date ofBiral mwdncn
Gendde�e/r(n"ndao)
SoeialSocuri �Number(fmmmmdw;
1- 23-I D
vrdale
o oq - l /-Off)
Walper.61forprrtfion. 14f11bout o signed waiver -from the subieet of the request, a complete criminal bistary, record may not
be releasable, per Code of roxg, Chapter 692.2. For complate criminal history record Infofsmtlon, as allowed bylaw, always
obtain a svalversl nsturd from the
sub eel of therequest.
i7Walver Ralmueoimbseit trod
i n fffiha eborate4Unneg Ndeial la condvd an loQualadnel Wooly 'Card ceryl pith the MIlrcn amiminnl
lavellfealiml(Mi). �Lty ahntml hismry dot
Ian me diel is meiotaultd by OloDClmt4l eo nleescdaeropw byfan•,
fyreiver5'tgntrfet
surra vJI AA alaa AAWLV4 cUMAIL ILAILU :K ACSU2LJ
• a (D(.j� mlr)
As of „-ab•! i So a search of the provided name and date of birth rovenlid: : • `ai:t=�
Nolowa Criminal History Record found with DCI %• . tr�'p -o
d p a 4F
Iowa Crlaiiuul HisloryRecord aAacbed, DCI # a 1 3 o0
,r o
DCI initials 1..
DCI -77 (Of /25110)
Received Timt Mal. 15. 2016 9:17AM No.9682
Mal•1-1. 2016 9:34AM Div of Criminal Investigation
No.9911 F. 3/3
SORA CR7MItAL DI9TORY
DCI 00669031
NON CONVICTION PAGE 1 ON 1
DATE PRINTED-
DCI:00869031 2016/03/21
NAME HAZOAJ,DUBTZN ROY
DOD SEX RAC HOT NOT EYE HAIR SRN POB
19900123 M N 602 220 RAZ BRO VT
ADDITIONAL IDRNTIPIRRS
CCH RECORD ••A
01 ARRESTED 20090604
AOEWCYr IA0570200 MARION PD
CHARGE NO- DS IA STATUTE IA124.4D1(5)
POSSESSION OF A CONTROLLED SUBSTANCE
TRR9: 5Ao06EC01
COURT DISPOSITION
AGENCY: IA057015J LIMN CO DIST COURT
COUNT NO- 01 IA STATUTES IA124.401(5)
POSOESSION OF A CONTROLLED SUBSTANCE
COURT CASE IDr 06971 SRCR083539
CHARGE CLASS: NON CONVICTION
TRRp1 5AO06ECOI
SUBSTANCE ABUSE EVALUATION
SENTENCE DISP EPF DAT
DEFERRED JUDGEMENT IY 20090910
PROBATION 1Y 20090910
DISCHARGED FROM 20100311
DEFERRED JUDGEMENT
AN ARREST WITHOUT DISFOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY TAB TOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAN
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINT'S FOR POSITIVE IDENTIFICATION THIS RECORD IS
EASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT TBE RECORD
COVERS TND 6UBJECT OF YOUR INOUIRY.
DIVISION OP' CRIMINAL INVESTIGATION
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