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Home My WebLink About17-008� r CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) . IDENTIFICATION NO. (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 Middle Last 2. Address (REQUIRED) _7 1()U q'�. <,j r>-�-+ /T� 3. Contact Information (REQUIRED) Email: a r hr z e\ GMa, I . (om Cell Phone: /t I� �teo �iiSma (All communicatid sent via email) 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 61 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 7. Have you been arrested / charged with any traffic offenses in the last five years? 3 Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty OthG Has your driver's liven auffeur's license been suspended or revoked in the last five years? Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using s diff) rent 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 h ve issued to me by the Iowa Department of Transportation a valid Driver's license number ` 7t-) 5� Z issued on 1-41-Ih expiring on 4-1 -11 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of ApplicantC--- Date l- 1317 Hf#Hf1f1Yi+}f1HH1f1l1lHTHH+HHH}+HHTHIHHf+#HH+H}HHHf HIH1+H}YffTT1f}H}fH11t!#1HYH#ITHH}1THHIH1RHHf #YlHHTiHH STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by c �[ on this 1 day of yVENOY S. MAYER . ` - (� ✓ (},/`Q'`t�� o comm��> 2� Notary Public ininCaio iofor the State of I wa . #HNMMMM1Hf11t'l0##1t#1HH##H#H#HiM1H1HH#H#HHHf.1H,Yf#+-I+.HftYiHMff'If 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). of er's icense .e hie or designee I Dates 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. Signature of Ci�rk or designee \ \\\3\n Date If1H H1f!'#11ffY#1+Yf1/Ylllffl}f1tH1fY11ttT1tH,H11+11flHHHlffHH #H11#fHY#Yi#fY Approved application DCI report State certified driving record Website update Office Use Only ; ; J 'd, Atj kilo ,,,I :L li l C I Nff LICZ CIeMrtAXIDRN ADGEAPPL9201ua ded.DOC 07/2016 C410WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN vuvvw•Iowadogov Office of Driver Services PO Box 9204 1 Des Moines, A 50306-9204 Phone: 515-244-9124 1 80D-532-1121 I Fax: 515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 1/13/2017 DL/ID #: 430WWO332 (IA) CDL Permit Class: None Customer #: 1943121 Class: D CDL Permit Issue None Date: Name: Montalvo, Eric Audit #: 9679405 CDL Permit None Expiration Date: Address: 2100 S SCOTT BLVD APT 83 Issue Date: 01/04/2016 CDL Permit None Endorsements: Expiration Date: 04/11/2019 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522403017 Endorsements: 3 ID Status: None Mailing 2100 S SCOTT BLVD APT 83 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 522403017 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 4/11/1978 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 02/02/2016 '02/22/2016 Improper RegistrationPohnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 02/04/2016 ',905839 'IA Name: Montalvo, Eric DL/ID: 43OWWO332 Pursuant to Iowa Code §321.10, 1, 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: -�ENICtf.,4� >: •""••. 1/13/2017 - IOWA tr"y D. 0 T ' c JU 7 RRIVEP ®S� Office of Driver Services Iowa Department of Transportation Name: Montalvo, Eric DL/ID: 430WWO332 in. ll. 2017 3:49 PM Div of Criminal Investigation No. IIhb Y. 1 •fi......... .. ... �... ..,.y Cl or .. .....,wm u,m .,tau use. 09/00/2017 13:'ar »a, x.002/002 STATE OFIOWA Crimir,ral History Recalyd Check Request Form To: fovea Division of Criminal investigation Support Operations Bureau, I" Floor 215 E. 7ta Street Des Moines, Iowa 50319 (515)725-6066 (515)725-6000 Fax I am reouestine an Iowa Criminal Histol Record Check on: UCI Account Number: _ 41_C CJ 114 - P (if applicable) From; _Ci(yoflowaCity City Clerk's Office 410 E. Washington Street Iowa City, lh 522a0 Phone: 319-356-5041 _ Fax: 319.356-5497 Last Name (n» ndmury) First Name (mandato) Middle Name (reeoabncnded) Mfr ✓� d -p, l nJo � r-; L N /-� Date Of Birth (inandietory) Gender (mandalory) Social Security Number (recommended) Pr , 1 t ( ) I f7 A d/hIalle DIFentaile 9 — -C.1 y Waiver ANforma ion; Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For co, mpletc criminal history record information, as allowts) by law, always obtain a waiver signature from the sub'ect of the request. Waiver Belease; i hereby give permission for the above reluesling official m eanduct an Iowa climiml history record check rvidS the Division of Criminal Investigation(DCO. Any uimklal history data concerning me dal is maintained by the DC(may be released n allowed by law. MaiverSignature: lvlra a..a,ealelaaa ■Aso ease V aaea.vau a.xra.a.xk iVwuaaa (DCI use only) As of `1 - la search of tho provided name and date of birth revealed: No Iowa Criminal History Record found with DCl } ® Iowa Criminal History Record attached, DCI # I ff 001 ;.t DCI initials DCI -77 (08/25/10) Received Time Jan, 9. 2017 12:07PM No. 1151 0