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Home My WebLink About17-021� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1 82 6 (3191356-5040 (319)356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. 1-7—o2-1 (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) `t 19 Vic:.{ ln_nr t in 3. Contact Information (REQUIRED) Email: cSL o r,. n e n zx 5 ac " L.c .MCell Phone:( tq) (All written communication sen via email) 4a. Driver's License expiratio b. Taxicab Business Name 5. Prior experience in trans 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Kin') Tvoe 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? W 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 yews? Type of offense Where When 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 d 7 A M 16 Z9 issued on t - 3: - 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. 1 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 (L N(1I C: 1C LJI r3jvI,5 Date ; - (0 1 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by AykgIALArj_ K. ACU r 1 1! Qpq n this LP - A day of F�%tl Ao.fu 7M7 . 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 142 -3h -o21 Signature of Policeief or designee eV 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. 'SQnatutp of City Clerkoresign Office Use Only Approved application DCI report State certified driving record Website update Dat ciarv✓rrvaDRIVBADGEAPP s20148�dWDOC 07/2016 Ci -G I 7"'°' . tire, T[a�gy 0 0 ciarv✓rrvaDRIVBADGEAPP s20148�dWDOC 07/2016 Cowa Department of Transportation Office of Doves Services (Toll Fme) 2nD -532.1121 PO Box 9704, Des Moines, IA 511~il}I 4204 515.244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: ..1/30/2017 DL/ID #: Name: McWilliams, Class: 1126182 Aushenna Komelia SUR Address: 3750 16TH AVE SW Audit #: 02/23/2024 CDL Cert Status: Issue Date: City/State: CEDAR RAPIDS, IA Expiration Date: NONE 524042301 Certified Corrective Lenses Restriction Endorsements: Mailing Address: 1571 CHASE ST Restrictions: 2/23/1991 Date of Birth: Mailing GARY, IN Sex: City/State: 464042021 CDL Medical Examiner's Certificate 107AM1029 (IA) Customer #: 6504393 A ID Status: None 1126182 DL Status: SUR 07/05/2016 CDL Status: SUR 02/23/2024 CDL Cert Status: Non -Excepted 319 369-8153 Medical Examiner Type Interstate NONE CDL Med Status: Certified Corrective Lenses Restriction None Date Added to CDLIS Driving Record Supplement: 2/23/1991 F 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 3urisdiction IA Medical Examiner Phone 319 369-8153 Medical Examiner Type Medical Doctor Medical Certificate Restriction 1 Wearing 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 Kornelia 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: 't�E�Ut(f 't41 1/30/2017 D. A. T.: �• m�.,.,,,cca� S �df�`� Office of Driver Services Iowa Department of Transporation Name: McWilliams, Aushenna Kornelia DL/ID: 107AM1029 1/30/2017 myBMV - Indiana Bureau of Motor Vehicles myBMV Plates And Vehicle Licenses Driver Suspension& my Home Registrations Titles And ID Cards Records Reinstatement Information Sign Out my Driver Records View Your Driver Record Official Driver Record Pay Reinstatement Fees Online Renew Your Dcense or to 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. �?a Norton pev.cra9 CY SYmantK ABOUT 551. CERTIFICATES my Driver Records Welcome, AUSHENNA KORNELIA MCWILLIAMSI ^Loading your driving record... AA NOTE: The BMV only retains supporting documentation for a period of ten (10) years AA License status: VALID As of 01/30/2017 5:13 pm IINT Current points: 0 Commercial Driver License (CDL) Information: CDLStatus: Valid CDL Expires: 02/23/2021 CDL Endorsements: CDL Class: A CDLRestdctions: B Commercial Learner Permit (CLP) Information: - CLP Expires: CLP Endorsements: CLP Class: CLP Restrictions: None CDLIS Status: LIC MD Self -Certification Status: Interstate - Non -Excepted IA Medical Certificate Status: Certified 38567 Medical Examiner's Certificate Information: Medical Certificate Issue Date: 06/06/2016 Medical Certificate Expire Date: 0510612018 Medical Certificate Restriction Codes: - Medical Examiners Name: JOSHUAPRUITT 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 Date: Convictions — (A indicates active points) FMCSA Medical Exemption Expiration Date: Disposition Offense Offense FMCSA Skills Performance Evaluation Effective Date: Date Pts Description Date FMCSA Skills Performance Evaluation Expiration Date: 05/20/2013 0 SEAT BELT VIOLATION 03/19/2013 Suspension Information -- (A indicates active suspensions) No Suspensions were found. Pending Suspension Information No Pending Suspensions were found. Disqualification Information — (A indicates active disqualifications) No Disqualifications were found. Pending Disqualification Information No Pending Disqualifications were found. Out of State Withdrawal Information No COS Withdrawals were found. Convictions — (A indicates active points) Disposition Offense Offense Susp Disq Date Pts Description Date Court / Case Number IDs IDs 05/20/2013 0 SEAT BELT VIOLATION 03/19/2013 LAKE SUP DIVISION #41 45DI21303IF01362 03/20/2013 0 SEAT BELT VIOLATION 0111712013 LAKE SUPERIOR 971 Acnnv.Ionn crvr�on httpsl/secure.in.gov/BMV/mybmv/MyDriver/DriverRecord.aspx 118 1/30/2017 myBMV - Indiana Bureau of Motor Vehicles IIIICIIIII VICUCI IIIGI IiJVC VGIC. I/ 1 /ILV IL, CApI1GlIV11 VGIC. OI IVILV IL, RCGO VI I. MMCIY V VL YV/V IiMRV, IIV'J 1/11 C, Control #: 3146532 Issue Date: 07/17/2012, Amend License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 Interim Credential Issue Date: 5/25/2012, Expiration Date: 6/24/2012, Reason: DUPLICATE DL, INSTATE, Control P. 2863400 Issue Date: 05/25/2012, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 Interim Credential Issue Date: 1126/2010, Expiration Date: 2/9/2010, Reason: DUPLICATE DL, INSTATE, Control #: 228853 Issue Date: 01126/2010, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/27/2015 Issue Date: 09/02/2009, Issue Operator, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 0312712015 Issue Dale: 05122(2009, Renew Permit, LEARNER PERMIT, Endorsements: None, Restrictions: B. Expiration Date: 05/31/2010 Issue Date: 0511212009, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 05/22/2009 Issue Date: 10105/2007, Issue Learner, LEARNER PERMIT, Endorsements: None, Restrictions: B, Expiration Date: 10/31/2008 Issue Date: 0811012004, 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 Date 04/30/2007 Issue Date: 03/04/1999, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 03/3112003 Remarks Remark Date:06111/2016 Moved to IA 160611 Remark Date:0410112015 ID Card voluntarily surrendered on: 411/2015 10:48:43 AM Remark Date:0312712015 License voluntarily surrendered on: 3/27/2015 5:16:17 PM Remark Date:05122/2009 ID Card voluntarily surrendered on: 5/2212009 3:44:33 PM Remark Date:1010512007 License voluntarily surrendered on: 1015/2007 3:24:00 PM ............................. End of Driver Record ' httpsl/secure.in.gov/BMV/mybmviMyDriver/DriverRecord.aspx 3/8 1/30/2017 myBM V - Indana Bureau of Motor Vehicles Yauul mu nrwloo 03/0712013 0 SEAT BELT VIOLATION 0110 8 /2 013 ELWOOD CIN! 48HO313021F001517 Mailing Addresses Effective Street Effective Street Address City State ZIP Code ID Dale Address City State 21P Code 3 08/24/2016 1571 CHASE ST GARY IN 464042021 IN 46403-2017 1 05112/2009 713 W 35TH AVE APT 4 GARY 2 07/1712012 7138 ASH AVE GARY IN 46403-2017 1 05/1212009 713 W 35TH AVE APT 4 GARY IN 46408-1555 Legal Addresses Credential Issuance Interim Credential Issue Date: 8/2412016, Expiration Date: 9123/2016, Reason: NEW ISSUE DI, OUT-OFSTATE, Control P.9355063 Issue Date: 08/2412016, Issue CDL, CDL CLASS A, Endorsements: None, Restrictions: B. Expiration Date: 02/23/2021 Interim Credential Issue Date: 411/2015, Expiration Date: 5/1/2015, Reason: RENEWAL DL W/O CARD, INSTATE, Control #: 7096947 Issue Dale: 04/01/2015, Renew License, OPERATOR, Endorsements: None, Restrictions: B. Expiraticn Dale: 06/27/2016 Interim Credential Issue Date: 3/2712015, Expiration Date: 412612015, Reason: RENEWAL ID W/O CARD, INSTATE, Control A 7082109 Issue Date: 03/2712015, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date: 04/0112015 Interim Credential Issue Date: 7/2312013, Expiration Date: 812212013, Reason: DUPLICATE DL, INSTATE, Control #. 4951377 Issue Date: 07/23/2013, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 I..\ /� A �.�I I��.... nom, �. -\l�-/l\01f C....1...a..... r\.A... OIC/Mnf 0.......... .\•�C,.Ifl fll \/.l//1 rA0A 1\I CT.\TC httpsJlsecure.in.govBMV/mybmv/MyDriver/DriverRecord.aspx 2/8 Effective Street ID Date Address City State ZIP Code 3 08/24/2016 1571 CHASE ST GARY IN 464D4-2021 2 07/17/2012 7138 ASH AVE GARY IN 46403-2017 1 05112/2009 713 W 35TH AVE APT 4 GARY IN 46408-1555 Credential Issuance Interim Credential Issue Date: 8/2412016, Expiration Date: 9123/2016, Reason: NEW ISSUE DI, OUT-OFSTATE, Control P.9355063 Issue Date: 08/2412016, Issue CDL, CDL CLASS A, Endorsements: None, Restrictions: B. Expiration Date: 02/23/2021 Interim Credential Issue Date: 411/2015, Expiration Date: 5/1/2015, Reason: RENEWAL DL W/O CARD, INSTATE, Control #: 7096947 Issue Dale: 04/01/2015, Renew License, OPERATOR, Endorsements: None, Restrictions: B. Expiraticn Dale: 06/27/2016 Interim Credential Issue Date: 3/2712015, Expiration Date: 412612015, Reason: RENEWAL ID W/O CARD, INSTATE, Control A 7082109 Issue Date: 03/2712015, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date: 04/0112015 Interim Credential Issue Date: 7/2312013, Expiration Date: 812212013, Reason: DUPLICATE DL, INSTATE, Control #. 4951377 Issue Date: 07/23/2013, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 I..\ /� A �.�I I��.... nom, �. -\l�-/l\01f C....1...a..... r\.A... OIC/Mnf 0.......... .\•�C,.Ifl fll \/.l//1 rA0A 1\I CT.\TC httpsJlsecure.in.govBMV/mybmv/MyDriver/DriverRecord.aspx 2/8 Ica. J. LV 11 J. YJI III Vlv VI VI IIIA IIaI in r ca 1. l Sal l Vu From:Clty or Iowa CITY Clark C11106 319 3666497 nv. L]LV 1. 1/ J 01/31/2017 11:27 0912 P.002/002 apliySTATE OF IOWA �Criminal History Recoyd Check ([ a lutvA"'i� Form' I� �,• To: Iowa Division of Criminal Investigation Support Operations Bureau, 1st Floor 215 T+. Ila Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6000 Fax T on, .crosaelina nn Tnwn Crintinnl Pktnry Record Check on: DCI Account Number: lTc – F (ifapplicabk) From: Cityoflowacity City Clerk's Office 410 Washington Street Iowa City, TA 52240 Phone: 319356-5041 Fax: 319-356-5497 LaaS1t Name (manda(ory) First Name (mandatory) Middle Name (rtcammended) II/(CltJt��tCt>n� l.t�lnJllf�ft(10. I[_vrft0.i-iCl- Date of Birth (mandaloo) Gender (mandatory) Social Security Number (reeommmdea va.b - 3, 1 R d1 ! � ❑Male L1Female 314 o 3' 34-53 Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Coda of lows, Chapter 692.2. For complete criminal history record information, as allowed bylaw, always obtain a waiver signature from the subject of the request. Wainer ReleaSe: I hereby give pamiss(on for above requesting official to conduct an Iowa criminal historyrccor4 check pith the Divisioa of Criminal hrvesligation(DCr). Nsycaiminal history data eossctmhsgmt 11101. is maintained by ale DCl maybe released as allosvcd by taw. 7 Waiver slgnaeure; , Il6&e 4, Lt.0 Iowa Criminal History Record Check Results (I)Cl use only) As of a\1 a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI — -t ❑ Iowa Criminal History Record attached, DCl # ` ' CD :z DCI initials— DCI-77 (0$/25/10) n- - .: - -- i T=-- I-- 91 fills Ia-IAAU u- nCAA 1