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HomeMy WebLinkAbout17-006l IDENTIFICATION NO. / �7 —oC7 (Office Use nly) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) 410 East Washington Street Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (319)356-5497 FAX First r( Middle �/// Last 1. Name (REQUIRED) �2WW JO In" p r � f10('waM 2. Address(REQUIRED) 5/ iClko%5 A7(Je 1 F0 DOSS /UZckt)(S sFi- 5-27(0 3. Contact Information (REQUIRED) Email: CCQvK /rcoe �s/nl c0.um Cell Phone: (31ci)JJg_ �fAll�communication sent via email) 4a. Driver's License expiration date (REQUIRED) ©Z 12 O ( 7 b. Taxicab Business Name (REQUIRED) yE I OW (�La oC Zo W 0. 5. Prior experience in transportation of passengers: Almp— 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? kk_ 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? M O Type of offense Where When 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? A)o Type of offense Where W here 9- Have you ever applied to be an Iowa City taxi driver using a different name? If yes, pleasepYtivide the nary) ss tv DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT ANDSTATE 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 herebyth t I have issued to me by the Iowa pa ment of Transport a valid Driver's license number -7(4 zV issued on 1 I l expiring on z O t . 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, Cha ter 2, of the City Code. (Needs to be s' ned in front of a Notary Public) Signature of Applic_.Dab % mix:�i+���+ky-eam�mw��s.+�mm:e*mN�tim�»m��xm�iis+m`r�mm�k+.�mr+�:e�swkt�mHshtx+:t::�:�wa�mmmmm�mt STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by T . l<,c�-24r, , on this ( ( 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). Expiration date of Driver's license t sj- Signature of Police Chief or designee glpl2-0 -Z-4 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. S-igndture of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update Date N O CJ V CledJTAXIDRIVBADGEAPPL9201UmendednoC 07/2016 N :n CledJTAXIDRIVBADGEAPPL9201UmendednoC 07/2016 C40%j DOT SMARTER I SIMPLER I CUSTOMER DRIVEN vvvvw•iowadotgov Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-91241800-532-11211 Fax: 515-239-1837 Www _lowadot.gov Certified Abstract of Driving Record Inquiry Date: 1/5/2017 DL/ID #: 769YY3726 (IA) CDL Permit Class: None Customer #: 677799 Class: C CDL Permit Issue None If"'••"' °ems =� Office of Driver Services �C 3 ' Date: Iowa Department of Transportation Name: Koedam, Jeremy Jonas Audit #: 1065482 CDL Permit None I0 7P7 f^9 Expiration Date: Address: 518 NICHOLS AVE Issue Date: 06/09/2016 CDL Permit None Cn Endorsements: Expiration Date: 04/30/2021 CDL Permit None Restrictions: City/State: NICHOLS, IA 527667721 Endorsements: NONE ID Status: None Mailing PO BOX 93 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing NICHOLS, IA 527660093 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 4/30/1982 CDL Cert Status: None Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Koedam, Jeremy Jonas DL/ID: 769YY3726 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: <V Name: Koedam, Jeremy Jonas DL/ID: 769YY3726 �.••'""'•:'A',.,,_Ik 1/5/2017 IOWA If"'••"' °ems =� Office of Driver Services �C 3 ' Iowa Department of Transportation —{f7 I0 7P7 f^9 N Cn Jan.11. TUI/ 11:1hAM Uiv of Criminal Investigation No.1099 P. 1/4 FI•.rrrr.a.r•y yr •JYvr� •...I•Y CI BIR V•I ICfY .1. JCtrOLLb/ 01/06/2017 16:61 x1777, P.002/002 • 1 ' STATE, Or IOWA Criminal History Record Check 0,11 Request Form ?n: Iowa Division of Criminal Investigation Support Operations Bureau, 111 Floor 215 E. 7" Street Des Moines, Iowa 50319 (315)725-6880 Fax I am renaesrinv an lnwa Criminal Iii ctnry Rrnn.A 01-1, DCI Accounl Number: (if applicable) Flom: Cqof lows C{ly _— City Clark's Office 410 E. Wpehia¢ton Street Phone: 319-3565041 Fax: 319-356-5497 Last Narac (mandatory) First Name (inandalory) Name (meommended) g0.��w>rl0 ADate of Birth (mandato JhViddIa Gender (n,00daw y)cial Security NDmbel' (recommended��-0—g r-rs- Waiver Xnfortnttfion: Without a signed waiver from the subject of file request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history, record information, as allowed by law, always obtain a maiver sI nature from the subject of the request. Waiver Release: I hereby give pmnission for We above rcqueslimg official to conducl an Iowa criminal history record thick wish the Division of erinlinsl hntstigaliot (DC. Any criminal history dale eoneem!ng me that is maintained by the DCI may be released as allowed by law. fi — 'aiverSignafur. Iowa Criminal history Record Check Results .. (UC�iue only] As of kVA�, a search of the provided name and date of birth revealed: No loava Criminal History Record found with DCI �r D -y; na ❑ Iowa Criminal History Record attached, DCJ #__ i s l DC] initials—k.— ii nitials OGl-Y/ (US/25/IU) Rectived Time Jan, 5. 2017 3:32PM No, 1020