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Home My WebLink About16-270rr"IIItJts'�� CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240.1826 (319) 356-5040 (319)356-5497 FAX 1. Name (REQUIRED) _ IDENTIFICATION NO. l I P — ZQ f) (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 r Last ,rt) -F 2. Address (REQUIRED) 91-7 NoS pec t O l lA)^^G�h 4. ,� t TA 3. Contact Information (REQUIRED) Email: Cell Phone: ?i i -vSP, 51L17 (All written dbmmuniGation sent via email) 4a. Driver's License expiration date (REQUIRED) `-2-3 - 2 b. Taxicab Business Name (REQUIRED) ttk�OQ (CA) 5. Prior experience in transportation of passengers: Mone 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? R Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When C, of Wr&( VVI�jKns pr 3z Z Clii3 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspende Plead Guilty) Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ Type of offense ✓v Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide tttame(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE?CERTiFIED •-- DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CFf{EF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available um request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certifX y that I have issued to me by the Iowa Department of Transportation a valid Driver's license number %13 XJ1177 issued on 1 2 -13 -(b expiring on �/ l ' L4 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 provision jof Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature ofApplicalH�.y r� Date 12 Iy-�� STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by L c _ ¢1 . (- fvf _�_ on this / L-) day of 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 I (2 3/Z(-(/ Signature of Police 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. Signatu ity Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update Date CIe,k,TMIDRIVBADGE WL92014amen .DOC 07/2016 r- s c:: r ry m CIe,k,TMIDRIVBADGE WL92014amen .DOC 07/2016 Page 1 of 1 CIJ10WADOT SMARTER I SIMPLER ICUSTOMER DRIVENWWW. Owadotgov OVUM of Driver Services PO BOX 9204 1 s IA Phone: 515-244-9124 1800-5322-112101 Fan; 515023�g37 37 www.iowadf.gov History Information Convictions Citation Date Conviction Date ___ ACD Explanation _ __ _ _ Count 06/05/2013 -- 107/24/2013 —�— — ----------_.. -- Y IUR Injurious Material on Highway ]ohnson 'IA Name: Groff, Lisa Marie DL/ID: 713XXIO72 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: c.. 4hi n 1�,........:�4 12/7/2016 �'. IOWA D. 0. T * �rcoa.v� Imo® — at '1Ii11 Iowa Department of Transportation Name: Groff, Lisa Marie DL/ID: 713XX1072 12/7/2016 Certified Abstract of Driving Record Inquiry Date: 12/7/2016 DL/ID #: 713XX1072(IA) Customer #: 1150325 Class: CDL Permit Class: None C CDL Permit Issue None Name: Groff, Lisa Marie Audit #: Date: 9999862 CDL Permit None Address: 917 PROSPECT PL Issue Date: Expiration Date: 05/12/2016 CDL Permit None Expiration Date: 09/23/2024 Endorsements: CDL Permit None City/State: WASHINGTON, IANE Endorsements: NONE Restrictions: ID Status: None Mailing Address: 917 PROSPECT PL Restrictions: Corrective Lenses Restriction None DL Status: VAL Mailing WASHINGTON, IA Supplement: CDL Status: None City/State: 523531216 CDL Permit Status: ELG Date of Birth: 9/23/1973 Sex: F CDL Cert Status: Excepted Intrastate CDL Med Status: None History Information Convictions Citation Date Conviction Date ___ ACD Explanation _ __ _ _ Count 06/05/2013 -- 107/24/2013 —�— — ----------_.. -- Y IUR Injurious Material on Highway ]ohnson 'IA Name: Groff, Lisa Marie DL/ID: 713XXIO72 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: c.. 4hi n 1�,........:�4 12/7/2016 �'. IOWA D. 0. T * �rcoa.v� Imo® — at '1Ii11 Iowa Department of Transportation Name: Groff, Lisa Marie DL/ID: 713XX1072 12/7/2016 72,L),:c. 9. 2016411 07AMcabDiv of Criminal Investigation No.9UBh Y. 1/2 o (FAX)3193382iuc r. uuL/002 �iu!ruoSTATE OF • , Criminal History Record Check , Request Form To' Iowa Division orCriminal investigation Support Operations Bureau, I" Floor 215 Z. 7" Street Des Moines, -lows 50319 (515)725.6066 - (5f3f725:6it�U Fsz —� DCI Account Number; 9967-F — ufappllsnDlq From; Yellow Cab of Iowa Ciry P.O. Box 428 Iowa City, IA. 52244 (319) 338.9777 Phonal Fax: (319)339-7302 am requesting an Iowa Criminal History Record Cheek on: Last Name (mandato First Name (mandatory) t I Middle Name (rewmmended �rQ DateofBirth (mandato ) Gender mendeto 'Social -Security Number (recomm Q73 ❑IVlaleFernale 176 -6q —" 40(`7 Waiver' Information, Without a slgnod, waiver from the subject of the regNost, it complete criminal history r000rd lnay not be releasable, per Code of Iowa, Chapter 692,2, For c leo criminal history racord Information, as allowed by law, always Waiver Release; I holeby alve perrilssion for the abo reaucsiina oRleial to conduct an Iowa eelminal eilnoryreeerd check Willi the Dlviaion of Criminal Invetdaedan (ocn. Any criminal hblory data eoncernlog hei lS mainuined by the DCI may be released As allowed by law, Waiver Signatu Iowa Criminal History Record Check Results (DCI u)c only) As of �, a search, of the provided name and date of birth revealed: I ❑ No Iowa Criminal History Record found with DCI c� 7 r Iowa Criminal History Record attaohad, DCI 9 S1p�3� rs N) v DCI initials1 2 DCI -?7 (08/25/10) Received Time Dec. 1, 2016 3:56PM_No.9553 8e c. 9. 2016 11:07AM Div of Criminal Investigation IOWA CRIMINAL HISTORY NON CONVICTION DCI;00569331 NAME: GROFF,LISA MARIE DOB SEX RAC 19730923 F W ADDITIONAL IDENTIFIERS TAT R HND O1 ARRESTED 19960215 AGENCY: IA0520400 CHARGE NO- 01 POSE SCH I TRK#! 018688301 COURT DISPOSITION AGENCY: IA052015J COUNT NO- 01 MGT WGT 505 103 CCH RECORD *** EYE HAIR RAZ BRO IOWA CITY UNIV SEC PD IA STATUTE IA124-401-5 JOHNSON CO DIST COURT IA STATUTE: IA124-401-5 No. 9085 DCI 00569331 PAGE 1 OF 1 DATE PRINTED - 2016/12/09 SKN POB IA POSSESSION OF SCHEDULE I MARIJUANA COURT CASE ID: 06521 SRCR046988 CHARGE CLASS: NON CONVICTION TRK#: 018688301 SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT DEFERRED JUDGEMENT 19980603 PROBATION lY 19950603 COMMUNITY SERVICE 25H 19980603 DISCHARGED FROM 19990317 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE,OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION P. 2/2 F1