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Home My WebLink About16-273.�r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. I — ;L%. (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 , Last 2. Address (REQUIRED) 14S1 �- �LoDtt t� ti kjtjA, Ct,' ) 1 A -aal} 3. Contact Information (REQUIRED) Email: Phone: 3I q SNT (All written communication sen is email) 4a. Driver's License expiration date (REQUIRED) _) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 4 4 Vow --s 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? v4:t— Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When SCA(-QO13 �r td .zi irAd �L. uz o��oZOi(� 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? YYv Type of offense Where When, ii 9. Have you ever applied to be an Iowa City taxi driver using a different name? 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) 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 W °JAF issued on CJ,b(n4 2S*piring on IZA-1tl�iil I understand that if 1 falsely answer any questions in this application, that this application may be denied. I agree that in making this application, 1 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 �myly= Date 12l �'_$ ( ) JL2 . STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by h 4' on this a8 day of Notaryublic in and for 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 City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Driver's license [ 7/5/ Signature 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. 4/.,m Signbture of City Clerk or designee /�-,Z_ /d�?//� Date XlXf1f1f11f11f111f1f}f!f!!f!M}+Hf++f44+}f+INfllfflfllfllfHlfflllf!!!1f!!f!l111+}f.!#+!`!f!}1!+}}}}�t+111N}11f11f111H!llfllffll11f4}flf+!}}+ Office Use Only Approved application DCI report State certified driving record Website update Oer MIDRN64DGEgP M014amai0Wd C 07/2016 C4610WADOT www.iowad'o'tgov SMARTER 1 SIMPLER I CUSTOMER bRWEN' Inquiry 12/15/2016 Date: Restriction None Customer 5597450 Endorsements: CDL Permit Name: Bod)ona, Bassai J Address: 431 S SCOTT BLVD City/State: IOWA CITY, IA None 522455526 Mailing 431 S SCOTT BLVD Address: Mailing IOWA CITY, IA City/State: 522455526 Date of 12/31/1985 Birth: Sex: M Convictions Office of Driver Services PO Box 92041 Des Moines, IA 50306-9204 Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837 www.iewadat.gov Certified Abstract of Driving Record DL/ID #: 413AF8068 (IA) CDL Permit Class: None Class: D Audit #: 1060738 Issue Date: 06/07/2016 Expiration 12/31/2020 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: SpeedScott ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG 01/20/2016 Status: SpeedScott CDL Cert Status: None IA CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County JUR 07/13/2013 821545 08/01/2013 01/20/2016 592 SpeedScott IA 08/03/2014 10/30/2014 N50 Improper Turn Johnson _ IIA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date ----�__---_---810536---- Case_ Number --_T__—_---- _ 1UR__ 08/03/2014 IA_ 10/13/2014 821545 _ IA ` 01/20/2016 1902821 IA Name: BodJona, Bassai J DL/ID: 413AF8068 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: ;•r""'••:!�'4y 12/15/2016 IOWA '� Cc� D. 0. T. /}.......Office of Driver Services IN% Iowa Department of Transportation Name: Bodjona, Bassal J DL/ID: 413AF8068 Uec, Io. ZUIU,� N:40RKL Ulv OT criminai Invesligallon uo.UUyl, r. vt Ffa _ lock ... 12/16/2016 12:2C ... 60 . .___/002 STATE OFIOWA Criminal ]History Reca>rd Chink To: Iowa Division ofcriminal Investigation Support Operations bureau, I1e Floor 215 L. 7" Street Iles Moines, Iowa 50319 (51 5) 725-0066 ($15) 725.6000 Fal. l an) remuestina an Iowa Criminal History Record Check on: DCI AccountNwnber._Y T � -- (if appligiblC) From: city of lows City_____ city Clark's Offtee 410 E. Washington Street Iowa Citw,*i9_52240 Phone: 319-356-5041 Fax: 319.356-5497 East N21MC onandatory) First Barrie (mandatory) N(iddh Name reeonunended) Jr o (1 � E— C J J -PGL Y1 - Date of Birth (mandalonq Gender (mandatory) Social 3ecuri 'Plumber (reummended) 13 I 0 111e ❑.female -1 q Pic) r Waiver rnforination. Witbout a signed waiver from the subject of the request, a complete criminal history record may not — be releasable, per Code of lows, Chrapte692.2. For complete criminal history record information, as allowed by low, always obtain a waiver signature from the subject of therequest. W(iiVCY IiCiCttSCa hemhy give pemliffiem (or the above mquuling olfic)al to conduct as loan Csimisml history reurd cheek with the Division of Geminal Investigation (DCI). Any criminal history dais concerning me Wel is mainlained by the DCI maybe released es allmee4 bylaw. Waiver-signatto•e: Iowa Criminal History Record Check Results (oft ufe only) As of �� o i (v —.,a search of the provided name and date of birth revealed: , No Iowa Criminal History Record found with DCl Iowa Crin)inal History Record attached, DCl DCI h)itials--�_ DCI -77 (08/25/10) Received Time Dec. 15. 2016 11i00AM No. 0024