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Home My WebLink About17-020I r 1 n�.:e®4 74 � r"111 cccccris CITY OF IOWA CITY 410 Easl Washington Streel Iowa City, Iowa 52240-1826 (3 19) 3S6-SO40 (319)356-5497 FAX 1. Name (REQUIRED) - IDENTIFICATION NO. V i - 02-0 (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 "reouired" information will result in denial of the application Middle Last 2. Address (REQUIRED) 47-9 Nst.thnar .rn 3. Contact Information (REQUIRED) Email:.�,� r 1 a c 1 ,Cell Phone: (All written communication sen via email) 4a. Driver's License expiration date (REQ1 b. Taxicab Business Name (REQUIRED) 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? 14Q_ 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 W here 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? iJt� Type of offense Where W hen' �o 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 her certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number C) A M ICS Z q issued on 1-31-1 7 expiring on 3 - Z; 17 . 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 Applicant a'LA 'NUO (n C` NO LJ I I ip In1 S Date 2 - 6 l � 0 (Vie 1...)..Q L.V' fY4Y#fY!##!Y#Y#*##llfiflf-F{#**fIHYY!{{#*#llYY4YY{#k*#!Y!!##fYllYYf###RN!*YMYY+{f#fYl4#####ilHllfYYi##*i!f#+#*4!4444+#+#4!!41!1###1NYlY#+#fY STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by ,ikvcP;A,A (,,_ X AC_UA ;) 1t C0g4n this L-07tA day of _AkAdo4U ZvO . 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 1(23/x-021 Signature of Police eff 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. '��Aup of Q lerk or designee _)_0 1 1 Date Office Use Only c� ^� Approved application DCI report Err - t�� State certified driving record Website update `? C.0 C7 CIe A%IDRI BA EAPPLM19ei dWDDC 0712016 Iowa Department of Transportation Office of Ofiver Sanikes (Toll Flee) 800-532.1121 PO Box 9204, Das Moines, IA SMW4204 515.244-9124 FAX 515.239.1837 Certified Abstract of Driving Record Inquiry Date: 1/30/2017 DL/ID #: 107AM1029 (IA) Customer #: 6504393 Name: McWilliams, Class: A ID Status: None Medical Examiner Jurisdiction Aushenna Komelia Medical Examiner Phone 319 369-8153 Medical Examiner Type Medical Doctor Address: 3750 16TH AVE SW Audit #: 1126182 DL Status: SUR Date Added to CDLIS Driving Record 07/05/2016 Issue Date: 07/05/2016 CDL Status: SUR City/State: CEDAR RAPIDS, IA Expiration Date: 02/23/2024 CDL Cert Status: Non Excepted 524042301 Interstate Endorsements: NONE CDL Med Status: Certified Mailing Address: 1571 CHASE ST Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 2/23/1991 Mailing GARY, IN Sex: F City/State: 464042021 CDL Medical Examiner's Certificate Certificate Specifics Explanations Medical Examiner First Name Joshua Medical Examiner Middle Name Allen Medical Examiner Last Name Pruitt Medical Examiner License Number 38567 Medical Examiner National Registry Number 9274182852 Medical Examiner Jurisdiction IA Medical Examiner Phone 319 369-8153 Medical Examiner Type Medical Doctor Medical Certificate Restriction 1 Wearinq corrective lenses Medical Certificate Issued Date 06/06/2016 Medical Certificate Expiration Date 06/06/2018 Date Added to CDLIS Driving Record 07/05/2016 History Information CLEAR DRIVING RECORD Name: McWilliams, Aushenna Komelia DL/ID: 107AM1029 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: -tlr(fht 1/30/2017 �IOWAd, , D.O.T. s •df� Office of Driver Services u' Iowa Department of Transporation Name: McWilliams, Aushenna Kornelia DL/ID: 107AM1029 1/30/2017 myamv Plates And Vehicle Licenses Home Registrations Titles And ID Cards my Driver Records View Your Driver Record Official Driver Record Pay Reinstatement Fees Online Renew Your License or ID Card View Your Recent Driver Notices Track Your Recent Renewals Replacement Licenses or IDs Schedule Driving Test Your Renewal Date CDL Self -Certify Driver Type Proceed to Checkout Click to Verify - This site chose VeriSign SSL for secure e- commerce and confidential communications. Norton SEC UREDO MOOT SSL CE AFIG Ea myBMV- Indiana Bureau of Motor Vehicles Driver Suspension 6 my Records Reinstatement Information my Driver Records Welcome, AUSHENNA KORNELM MC WILLIAMSI ^ Loading your driving record... Sign Out " NOTE: The BMV only retains supporting documentation for a period of len (10) years '• License status: VALID As of 01/30/2017 5:13 pm IINT Current points: 0 Commercial Driver License (CDL) Information: CDL Status: Valid CDL Expires: 0212312021 CDL Class: A Commercial Learner Permit (CLP) Information: CLP Expires: CLP Class: CDUS Status: UC Self -Certification Status: Interstate - Non -Excepted Medical Certificate Status: Certified Medical Examiner's Certificate Information: CDL Endorsements: CDL Restrictions: B CIP Endorsements: CLP Restrictions: None Medical Certificate Issue Date: 06106/2016 Medical Certificate Expire Date: 06106/2018 Medical Certificate Restriction Codes: - Medical Examiners Name: JOSHUA PRUITT Medical Examiners Phone Number. 3193697105 Medical Examiners Speciality Code: MD Medical Examiners Jurisdiction: IA Medical Examiners Jurisdiction License Number, 38567 Medical Examiners FMCSA National Registry Number. 9274182852 FMCSA Medical Exemption Effective Dale: FMCSA Medical Exemption Expiration Dale: FMCSA Skills Performance Evaluation Effective Date: FMCSA Skills Performance Evaluation Expiration Date: Suspension Information — (• indicates active suspensions) No Suspensions were found. Pending Suspension Information No Pending Suspensions were found. Disqualification Information — (• indicates active disqualifications) No Disqualifications were found. Pending Disqualification Information No Pending Disqualifications were found. Out of State Withdrawal Information No OOS Withdrawals were found. Convictions — (• indicates active points) Disposition Offense Date Pts Description 05/20/2013 0 SEAT BELT VIOLATION 03!20/2013 0 SEAT BELT VIOLATION httpsJ/secure.imgovBM V/mybmv/MyDriver/DriverRecord.aspx Offense Susp Disq Date Court / Case Number IDs IDs 03/1912013 LAKE SUP DIVISION #41 45D1213031FD1362 01/17/2013 LAKE SUPERIOR #71 �cr,n-r,annvm-ren 118 1/30/2017 myBMV - Indiana Bureau of Motor Vehicles II IICIIIII VICUCIIUa11Ji Utl VGIC. /I 11/LV IL, Cxp11GlI V11 VGIC. W IV/LV IL, M1CG.lN1. M1Y1CRU VL YY/V VMRV, IIY-.]IRI C, Control #: 3146532 Issue Date: 07/1712012, Amend License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03!2712015 Interim Credential Issue Date: 5125/2012, Expiration Date: 6/24/2012, Reason: DUPLICATE DL, INSTATE, Control #: 2863400 Issue Date: 05/25/2012, Duplicate License, OPERATOR, Endorsements: None, Restrictions: S. Expiration Dale: 03/27/2015 Interim Credential Issue Date: 1/2612010, Expiration Date., 21912010, Reason: DUPLICATE DL, INSTATE, Control #: 228853 Issue Date: 01/26/2010, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/2712015 Issue Date: 09/0212009, Issue Operator, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/2712015 Issue Dale: 05/22/2009, Renew Permit, LEARNER PERMIT, Endorsements: None, Restrictions: B, Expiration Date: 05/31/2010 Issue Date: 05/12/2009, Renew ID Cana, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 05/22/2009 Issue Date: 10/05/2007, Issue Leamer, LEARNER PERMIT, Endorsements: None, Restrictions: B, Expiration Date: 10/31/2008 Issue Date: 08/10/2004, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 10/05/2007 Issue Date: 04/05/2003, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Dale. 04/30/2007 Issue Date: 03/04/1999, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Dale. 03/31/2003 Remarks Remark Date:0611112016 Moved to IA 160611 Remark Date:04/0112015 ID Card voluntarily surrendered on: 4/1/2015 10:48:43 AM Remark Date:03/2712015 License voluntarily surrendered on: 3/27/2015 5:16:17 PM Remark Date:0512212009 ID Card voluntarily surrendered on: 5122/2009 3:44:33 PM Remark Date:10/0512007 License voluntadly surrendered on: 1015/2007 3:24:00 PM ............................. End of Driver Record httpsJ/secure.in.gov/BMV/mybmv/MyDriver/DriverRecord.aspx 318 1/30/2017 myBM V - Indiana Bureau of Motor Vehicles wvm uu urwrua 03/07/2013 0 SEAT BELT VIOLATION 0110812013 ELWOOD CITY / 48H0313021F001517 Mailing Addresses Legal Addresses Effective Street ID Date Address City Slate ZIP Code 3 08/24/2016 1571 CHASE ST GARY IN 464042021 3 06124/2016 1571 CHASE ST GARY IN 46404-2021 2 07/17/2012 7138 ASH AVE GARY IN 46403-2017 1 05/12/2009 713 W 35TH AVE APT 4 GARY IN 46408-1555 1 05/1212009 713 W 35TH AVE APT 4 GARY IN 46408-1555 Legal Addresses Effective Street ID Date Address City State ZIP Code 3 06124/2016 1571 CHASE ST GARY IN 46404-2021 2 07117/2012 7136 ASH AVE GARY IN 464032017 1 05/12/2009 713 W 35TH AVE APT 4 GARY IN 46408-1555 Credential Issuance Interim Credential Issue Date: 8/24/2016, Expiration Date: 9123/2016, Reason: NEW ISSUE DL, OUT-OF-STATE, Control #. 9355063 Issue Date: 08/2412016, Issue CDL, CDL CLASS A, Endorsements: None, Restrictions: B, Expiration Date: 02/2312021 Interim Credential Issue Date: 4/1/2015, Expiration Date: 511/2015, Reason: RENEWAL DL W1O CARD, INSTATE, Control #: 7096947 Issue Date: 04/01/2015, Renew License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 06/27/2016 Interim Credential Issue Date: 3/2712015, Expiration Date: 4/26/2015, Reason: RENEWAL ID W/O CARD, INSTATE, Control ik 7082109 Issue Date: 03/2712015, Renew ID Cant, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date: 04/01/2015 Interim Credential Issue Date: 7/23/2013, Expiration Date: 812212013, Reason: DUPLICATE DL, INSTATE, Control #: 4951377 Issue Date: 0712312013. Duplicate License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 https:/Isecure.in.gov/BMV/mybmv/MyDriver/DriverRecord.aspx 2f8 I CU. J. IV I I l. R J I n l V l e V I v l l III l Ila I I is v e at I e at IV it Ffom:Ciry or Iowa City Clerk Office 31G 3a:s8497 0V. LILV 1. 1/ J 01/31/2017 11:27 9012 P.002/002 �l .it IOWA l i tI� History 'a I !' I ILS tot) 1° Request 1Form To: Iowa Division of Criminal Investigation Support Operations Bureau, PI Floor 2151;. 7" Street - Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6000 Fax I am reoueslinc an Iowa Criminal Aistory Record Check on: DCI Account Number: (ifappticabtc) From: _CiWoflowacity City Clerk's Off -ice 4101;, Washington Sirect Iowa City, lA 52240 Phone: 319356-5041 Fox: 319-356-5497 Last Name (mandatory) Name (mandatory) Middle Name (regia amended) �rlCUj;It; aYvi.5 First t t �l��lfaP�l10. I[_orfl0-ticl— Date of Birth (mandatory) Gender (ntandalory) social Security Number (reeommmdea Fab 3 I R 91 ❑Male LlFemale 316 U 3' 31183 Waiver Inforillation. 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 complete criminal history record information, as allowed by law, always obtain a witiver signature from the subject of the request. Waiver AeleaSe: I hereby give permission for above requesting olTeial to conduct an Iowa criminal hisloryrcwfd check With IheDivls(on of(.4iminal Inveatigation (DCO. My airninal history damoni1zeembtgm^c lhelis meinlained�bydie DClmay;Jbnerelaased as allowed by larv. Waiver Signature: r Iowa Criminal history Record_ Check Results (DCI late only) As of r�i.1� a search of the provided name and date of birth revealed: r.. No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, ))Cl # ' o DCI initials u DCI -77 (08125110) h --- :_._J r:-- 1-- 11 nnll em-InAIA II- 9CAn