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Home My WebLink About17-033�r t +. MIS®i�IL CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-S040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. � -i — 0,- 3 (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 11(:N/R6/L Middle h C.�/I/' �ow0� Last n.AeI C5 3. Contact Information (REQUIRED) Email: 6" , Cell Phone: 31 e,�' (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) G�/c%oi6 b. Taxicab Business Name (REQUIRED) yEz-aaW (,'Pe of Sojo., I iy 5. Prior experience in transportation of passengers: 741? 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /?a Type of offense What happened to the charge? (Circle one) Convicted Dismissed Where Deferred Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When Other -`1 0 When 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? ^, d Type of offense Where When,. a 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please providethe name(s) n0 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 F1 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 ;� 28 '1rt'1 fissued on -•.2-0ci3 expiring on 4//4420 1 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 /� Date 20/ % If1NlHlffl11f1f1111ff 111fH111ffffflHillNflff11f11ff 1111 1111 kllffflf!!llfllffHlflflfHf 1ff11f11ff1f1111f 11f!!1f!llflf 1111! 11!!!11ltf 111!1 if STATE OF IOWA ) COUNTY OF JOHNSON ) scribed and rrLto before me by Ec,,rLes on this Z—_ 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 vo))� -- Signature of Police Chief or designee 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 City Cferk or designee j Office Use Only Approved application DCI report State certified driving record Website update a /7 Dat CWff IDRNaaoGEAPPLe2014en*,.ded.DOC 07/2016 /&L**r4jj:10WA00T vvvvw.iowadotgov SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-91241800-532-11211 Fax: 515-239-1837 www.iowadot-gov Certified Abstract of Driving Record Inquiry Date: 3/2/2017 DL/ID s: 228AD8474 (IA) CDL Permit Class: None Customer s: 687190 Class: A CDL Permit Issue Date: None Name: Earles, Michael Allan Audit »: 7084993 CDL Permit Expiration None Medical Certificate Issued Date 11/16/2015 Medical Certificate Expiration Date 11/16/2017 Date: 11/17/2015 Address: 32 GLEASON DR Issue Date: 06/29/2013 CDL Permit None Endorsements: Expiration Date: 06/16/2018 CDL Permit Restrictions: None City/state: IOWA CITY, IA 522405838 Endorsements: NONE ID Status: None Mailing Address: 32 GLEASON DR Restrictions: Corrective Lenses DL Status: VAL Restriction None CDL Status: VAL Mailing IOWA CITY, IA 522405838 Supplement CDL Permit Status: ELG City/State: Date of Birth: 6/16/1956 CDL Cert Status: Non -Excepted Interstate Sex: M CDL Med Status: Certified CDL Medical Examiner's Certificate Certificate Specifics Explanations Medical Examiner First Name Jeremy Medical Examiner Middle Name Lewis Medical Examiner Last Name Nelson Medical Examiner License Number 002023 Medical Examiner National Registry Number 7661525813 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 358-5736 Medical Examiner Type Physician Assistant Medical Certificate Issued Date 11/16/2015 Medical Certificate Expiration Date 11/16/2017 Date Added to COLIS Driving Record 11/17/2015 History Information CLEAR DRIVING RECORD Name: Earles, Michael Allan DL/ID: 228AD8474 Pursuant to Iowa Code 4321.10, 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: l4 3/2/2017 D. IO0. WA L JYA C Office of Driver Services �Ngvvw.. Iowa Department of Transportation l Name: Earles, Michael Allan DL/ID: 228AD8474 F1-eb21. 2011 lU,h4RMcorDiv of Criminal Investigation ozrzsizo,� ,,,�No.4)Ud r. 1/0 ooz STATE CIF IOWA Criminal History Record Check @IV Request Form DC1 Account Number !-Jc>B (if applicahk) To: lona Division of Criminal Investigation From: Ctty of Iowa CitV _ Support Operations Borcan, 1" Floor City Clerk's Office T 215 E. 7" Street 410 E. Washington Strael Des Moines, Iowa 50319 R --- _17,4-6n66 Iaays. l 2240--- (51S) 725-6000 240(51S)725-6000 Fax Phone; 319-3$6-5041 Fax: 319-356.5491 lam reouestino an InviA Criminal Iiietmv Rernrrl Chcel no• Last Name (mandator) First Name (mandatory) Middle Name (recommended) v Date of Birth (mandatory) Gend,.eerr (msndstory) Social SecurityNumber (rewmmmded) Rrmale ❑Female /-/S- - 7q-,24415^ Waiver Injorniafionr 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_ mnlete criminal history record information, as allowed by taw, always obtain a waiver signature from the subject of the request, Waiver Release;1 hereby give pem,issian rot the above sequemling official to conduct an li criminal history record check with the Division of Lliminsl Invesligatfon (DCO, My (Aminal history data concerning me that is maintained by We DCI may be released as allowed by lay. Waiver Signature:^(7 � I,i Iowa Criminal History Record Cheek Results (DCI use only) As of a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DO Iowa Criminal History Record attached, DCI # DCl inilials_� , DCI -77 (08/25/10) Received Time Feb,13, 2017 10:24AM No -4221