HomeMy WebLinkAbout17-035.�r t
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) .
2. Address (REQUIRED)
IDENTIFICATION NO. / 7
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
3. Contact Information (REQUIRED) Email:
4a. Driver's License expiration date (REQUIRED) -
b. Taxicab Business Name (REQUIRED) j>[
5. Prior experience in transportation of passengers:
Middle
cKOY� 400.rom Cell Phone:
communication sent via email)
03 Z 7 136--� I /151/2o(ff
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead G\uyt ty Other
Have you been arrested / charged with any traffic offenses in the last five years? T i `)
Type of offense Where W h n
��// / T
JQ -Wtj6. WA`f (IN UN6 WA-�, 1�1�t%a i l.f �, Lw. J1 ) 1 _ ZG i
What happened to the charge? (Circle one)
ter.
Convicted Dismissed Deferred Suspended Bead Guilty Otherc� NC
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?, A;(.)
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)
I /_ - -
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIOIED
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 certiN that I have sue to me by the Iowa D p rtment of Transportati n ra valid Driver's license number
js Ja 0� Z3is
issued on r expiring on 1 G . I understand that if I
-falsely answer any questions in this application, that this appli ion 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 furthef agree that, if authorization to be a taxicab driver is granted, to compfy at all
times with all of the proyisioins pf Tide 5, Ch pter , pf the City Code. (Needs to be signed in front of a Notary Public)
(
MY
/1 7
Signature of Applicant / Date
i
lHHllfHlf flfl#Yf1111fH1f!!Mfll1HlNHlHlHflf fflri'YF#ff#11111#lYlffff#YH#kY#ffff#44ft444NfflYfff11ff1N1ff1fll11fl111f1f 111!1!11 f f!f!!f
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by L< IT or on this day of
, Acaki 1A 7-01 77--. \ n 1 I
Public intend for the—State 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 zo-t
I
)0 1
Signature of Police Chief or designee
�7/Z1/%
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.
z,
Signature of City! Jerk or designee
11111#Ifff'liflffflflf.lYYYfffiflf}f'#1#1f1YlM#fHl.,f11f1111111H11fl1fllfll,N.,111f1f111f11f111f,fllf #Yf!#lffff Y#1f
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CI ry AxIDRM nDceAPPtszoia .dW DOC 07/2016
i7
Date
11111#Ifff'liflffflflf.lYYYfffiflf}f'#1#1f1YlM#fHl.,f11f1111111H11fl1fllfll,N.,111f1f111f11f111f,fllf #Yf!#lffff Y#1f
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CI ry AxIDRM nDceAPPtszoia .dW DOC 07/2016
Iowa Department of Transportation
Office d Drfou Sewer (Tdr ffee) 8D0-532.1121
PO Box 9204, Lies IAMM, IA 50306-9204 515-2443124
KAJC 51 5-23W183?
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
2/21/2017
DL/ID #:
803ZZ2363 (IA)
Customer aa:
3636560
Name:
Vornbrock, Rick
Class:
D
ID Status:
None
Soeed
Page
IA
Address:
1612 DERWEN DR
Audit #:
1597308
DL Status:
VAL
Issue Date:
02/07/2017
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
01/09/2018
CDL Cert Status:
None
522464923
Endorsements:
3
CDL Med Status:
None
Mailing Address:
1612 DERWEN DR
Restrictions:
Corrective Lenses
Restriction
None
Supplement:
Date of Birth:
1/9/1951
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522464923
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
08/18/2013
08/21/2013
N63
Driving Wrong Way
on One Way Street
Johnson
IA
02/1 2015
02/27/2015
S92
Soeed
Johnson
IA
Name: Vornbrock, Rick Page DL/ID: 803ZZ2363
Pursuant to Iowa Code 4321.10, 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:
2/21/2017
' IOwn
D. 0. T. *
ysrNMNu Office of Driver Services
Iowa Department of Transporation
02/teb.Z3. 201/t11:23AMCabDiv of Criminal Investigation (Fax)3193332;No.4342
Idy MSTATE OF IOWA
,,� tRecord
Request r
rm
P. 1/l/ooz
rs'm
Tor lows Division of Criminal Investigation
Support Opera(lons Bureau, 141 Floor
215 Tt. 7'a streot
Des Moines, Iowa 50319
fare\ n•r•.'All
DCT Account Number; _99674
( raapnaabte)
From; Yellow Cab ofJlowa City
P.O. Box 428
XOWA Clty, IA. 52244
(319) 938-9777
Phone)
Faxl (319) 339.7302
•.•a, gruv roeammandad
oRN�rioci: IR.C'k Pay
to Of B1Yth (mrnd—I
_. GBttd BY
L —•• -••w ,+vwmmenaa
❑P'ettaola �7`'`7Jr7F, 6c� c?, I
rrarver in/ormafron Without a slgnad waiver from tho 3ublect of the regpest, a eompigte gr)minal history record may no
be releaseble, per Code of Iowa, Chapter 691,2, For complete criminal history -record Informallon, as allowed by law, always
obtain a waiver sl netura from the sub ect of eho request,
Wafyar Re%aSe: I herebyglyo pormissloh for the above requ Ing om tel to netucl an low riminel history record check with the Division orcriminal
Investigation (DCO. My horob el htuory data a t ma th h ainuln b t o DCI may b
Y y learad u allowed by law.
Waiver Signarur , t
-------------
�..=aaaarxx &AANyyry tcecolrg Uleck xtestiIts
(DCI use only)
As of. _ it search of the provided name and date of birth rovealed:
No Iowa Criminal History Record found with DCI
W
Iowa Criminal History Record attached, DCI # L
DCI inidals�&
DC147 (08/25/10)
Received Time Feb. 21• 2017 2:22PM No. 4071