HomeMy WebLinkAbout17-040IDENTIFICATION NO.
1 r 1 (Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
I'' Firf Middle Last
1. Name (REQUIRED) _tt f C4Ae
2. Address (REQUIRED) tsl sn t^Lt (F S 6 r7 zlT-o e )cL
3. Contact Information (REQUIRED) Email: d�/Cd.bq rV! ��Poo,crwCell Phone:
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED)02-(o
b. Taxicab Business Name (REQUIRED) A O.y Cd r5 LNC f
5. Prior experience in transportation of passengers:
r
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 xxG'uilty Other
Have you been arrested / charged with any traffic offenses in the last five years? Iy t7
Type of offense
What happened to the charge? (Circle one)
Where
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? 07
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 here y c ifyltb have issued to me by the Iowa De artent of Transportation va Driver's license number
(f1 9�O issued on 06 6( 20/ xpiring onZ 03 I understand that if I
falsely answer any questions in this application, that this application may be denied. I agr a th tin making this application,
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 tothis ap lication, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisio o itle 5, Chapter 2, of the City Co e. (Needs to be signed in front
of a Notary Public)
Signature of Applicant Date ;7
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 13ejTAAt R. L -L. rj CoFf- on this q day of
YNDY & MAYER I -
lmiWw Number 72042!
w cnmmaLvn DOM Notary PublidAn and for the Stelfe of Iowa
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 l�l��/Gc�} q
Signature of Police Chief or designee
'3 I,01 1;!�t,;7
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.
- 3&/ 7
of City Clerk designee F Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Ger✓TAXIMNBADGEAPPL92019ame .DOC 07/2016
C410WADOT
vvww.iowadotgov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-91241 BDO-532-11211 Fax 515-239-1837
www.towadot.gov
Inquiry 2/28/2017
Date:
Customer #: 1621790
Certified Abstract of Driving Record
DL/ID #: 636MM7805 (IA) CDL Permit Class: None
Class:
0
Name:
Lubaroff, Helene Marie
Audit #:
7195672
Address:
1514 SPRUCE ST
Issue Date:
08/01/2013
CDL Permit
None
Expiration
02/03/2019
ID Status:
None
Date:
VAL
City/State:
IOWA CITY, IA 522406030
Endorsements:
3
Mailing
1514 SPRUCE ST
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA 522406030
Supplement:
City/State:
Date of
2/3/1966
Birth:
Sex:
F
History Information
CLEAR DRIVING RECORD
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
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:
!.1"""•��'�4, 2/28/2017
IOWA °
D. 0. T.;ia'.r1
Office of Driver Services
Iowa Department of Transportation
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
Ma i. 1. 2017,. 4: 24PM
.1
Div of Criminal InvestigationNo. 4778 P. 1/2
r r.1 I%. .HI V V i
STATE OF IOWA
Criminal History Record Check
Request Form ^:
To: Iowa Dwon of Crlminal loveatiptloo
Support Operation@ Bureau, I" Floor
216 L 7" Street
on Alolnes, Iowa 60319
(513) 72Se1010 In
r ............N.... G.... h:.w:n.l 4liarwry Qwrnrvl !^iur•4 nn�
DCI ACODUM NUmhes:FC-
(a-&W+m*)
From) VAa rcrs TAx I
116 5{evcNs Or-
-
Phone: (3(4 339-'
Far:. • 3(9) 551-
0
L Natae mmaow ) �
First Name (mad.
Middle Name ism
/ut
Date e(VII-MOMMAIMM
Genderivt
SoclQQal Seen Number
Q 4 O3 / q6.
❑Mate oFemale
Walvtrl'ri/browdon: Without a elped waiver from the subjaa of the rsqumt, a complete erimwal history retard may not
be rataeoble, per Cede or Iowa, Chapter 692.2. For DlMkb erimissl hW9ry record Istormatles, u snowed by law, always
Obtain a walver gesture from the sub tet otthe rmmt
WatVdrRelease:IbembylevepewwionfworoWowrogp lnronkinlwmMuctmIonaeftbalhirsyW.04chuckWUeKDivisionofComlokl
1nmUplion (DCO. Any 9WW hlewr OarNm it mehiuhwd by the CJ be releue dlev d b Inv, .
Walver S4gniffmi
Iowa Criminal History RccorA Check Results tDCiweenty)
As of !' a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record attached, DO k
DCI initial_
Received Time Feb, 28. 2017 11:14AM No. 4514