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Home My WebLink About17-054CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 5 22 40-1 826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. / -7-D59 (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) SIR Phone:3/3-350,757/ (All written communication sent via email)' 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED)/,�4//tit A/ ,z 5. Prior experience in transportation of passengers: 64iytrsi/ L,*,C a- 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? _" / Pr r Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilt Other 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 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? 141/0 Type of offense Where When 2017 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 S,�_L3 (s i issued on 10—/Y xpiring on 7—If— 2 1. 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 Applicant7pet,✓ f- 15: Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by 1�xa2(lr _ �n� tZ on this day of Public W and for the State 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 Signature of Police Chief or designee Date AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO MOIRA THAN OFROM THE DATE LISTED BELOW. ffovl;� l7 Signature of City Clerk or designee I D to Office Use Only Approved application DCI report State certified driving record Website update Gerk/rAXIDRIVRADGEAPPL92014am ded.DOC CITY€II=IC-CITYCLERK 2017 APR 14 PM2:11 07/2016 Page 1 of 2 C1410WADOT wvvw,iowadotgov SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Box 9204 1 Des Moines, A 50306-9204 Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837 www.iowadot.gov Inquiry 4/11/2017 Date: Customer 3190100 Name: Boltz, Robert Adam Address: 13 DATA DR City/State: IOWA CITY, IA 522403010 Mailing 13 DATA DR Address: Mailing IOWA CITY, IA City/State: 522403010 Date of 7/15/1958 Birth: Sex: M Certified Abstract of Driving Record DL/ID #: 345AE5367 (IA) CDL Permit Class: None Class: D CDL Permit Issue None Date: Audit #: 7809892 CDL Permit None Expiration Date: Issue Date: 02/20/2014 CDL Permit None Endorsements: Expiration 07/15/2021 CDL Permit None Date: Restrictions: Endorsements: 3L ID Status: EXP Restrictions: Corrective Lenses DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Status: CDL Cert Status: None History Information CLEAR DRIVING RECORD Name: Boltz, Robert Adam DL/ID: 345AE5367 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: Name: Boltz, Robert Adam DL/ID: 345AE5367 •;� 4//111//2017 IOWA N*I;/Lda.tl�f CITYPGFIC-CITYCL 1=fK r'••••••'g Office of Driver Servicesn Iowa Department of Transportation L�� APR 1� FML•• 1� 4/11/2017 F,Apr.13• 2011„ 4: 11 FMC,a,Uiv of Criminal Investigation 0-11012017 16:;No. 13243f,J. 1,o2/O o2 STATE GIF 10W.A Crrlimkia@ History ileeo.rd Check 't Requat Pored , ,r Y At, 7. r(dra.u�a �l4.VT��'��Y •. DCI Aecou» t Number: VQL-)Z'--r—v_ prappunabiq To: lova Division of Criminal Investigation Proln: _City of lows City Support OperaraonsBureau,1 Floor CityCteric'sOffico __ 215 E. 7'a Street 410 E. Washington street Des Moines, Iowa SU319 — (51 -5) -Z35 -6W6 leet�Eit ,�I{s�234U— (515) 725-6000 Pax - '"---.'-- Phone: 319-3S6-5041 Fax; 319.356-3497 111311'etlUe5tll12 all roVVa 12risllinal M -On l Recnrrl Chwnir nm T 1st lame (mmsdatory) _^ First Name (mandaion9 Middle IVaroe (raaon meodad) WC) e vQ�9 1 - Date of Birth inundatory) _ Gender (mondalory) Social Security lumber recommended) Elk a10 ®Female Mitiver- Infori'ttttfiorl: Wi(houta signed waiver from thesubject of the request, a complete criminal bistoq, record may not be releasable, per Code of Iowa, Chapter 692.2, For co_ mplote criminal history record information, as allowed by law always obtain a waiver signature from the sub eet of tho re uest. iytliver Release; ( hereby give permission for We above nquuting official to conduce an IOwa criminal history record check with the Division blCriminal hlvetllgatiaa (DO). Any criminal hisldry daln cancerning me that is malnmined by the DCI maybe released as allowed by law. _ Waiver Signoturel �Mara �Criminal History Record Check Results (Dcl,ne only) As of —I t ✓ 1. 1 —, a search of the provided name and date of birth revealed: 13 No Iowa Criminal History Record found with DCI t� Iowa Criminal history Record attached, DCI i1 - I I �p CITY0FIC2 ITYCI_PC 201E APW14 PH2:1 1 -- DCI initials - DC!-77 (08125110) Received Time Apr. 10. 2017 4:04PM UAW Apr.13, 2011 4:21PM Div of Criminal Investigation No.8243 P. 2 __ • DCI:00421715 NAME: BOLTZ,ROBERT BOLTZ,ROBZRT ADAM DOB SEX RAC 19580715 M W ADDITIONAL IDENTIFIERS TAT L SHLD TAT UL ARM IOWA CRIMINAL HISTORY DCI 00421716 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 3 DATE PRINTED - 2017/04/13 HGT WGT EYE HAIR SYN POB 510 190 BLV BRO FAR PA DISP EFF DAT 19911011 19911011 19911011 DISP EFF DAT 19911022 19911022 (MYOFIC—CITYC1_CRK 2017 APR 14 PM2:12 CCH RECORD *" 01 ARRESTBD/TAKEN INTO CUSTODY 19910629 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA236-2-2A ASSLT'CAUSR INJ DOMESTIC TRX#: L399087O1 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA236-12 ASSAULT CAUSE INJURY CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L39988701 RESTITUTION SENTENCE JAIL 45D PROBATION lY SUSPENDED 225D BATTERERS AND SUBS ABUSE TRTMNT 02 ARRESTED/TAKEN INTO CUSTODY 19911018 AGENCY: IADS2O0DO JOHNSON CO SO CHARGE NO- 01 IA STATUTE IA236-11 VIOL NO CONTACT ORDER TRK#: L399BBBO1 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA236-11 VIOLATION NO CONTACT ORDER CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L399BBBOI SENTENCE JAIL 35D COURT COSTS 51) CREDIT FOR TIME 03 ARRESTED/TAKEN INTO CUSTODY 19911122 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA321J-2 OWI IST TRK#: L39960901 DISP EFF DAT 19911011 19911011 19911011 DISP EFF DAT 19911022 19911022 (MYOFIC—CITYC1_CRK 2017 APR 14 PM2:12 Apr,13. 2017 4; 26 PM Div of Criminal Investigation COURT DISPOSITION AGENCY: IAD52DISJ JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321J-2 OWI -2ND OFF CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L39988901 SENTENCE JAIL 360D DL BARRED 6Y -PAID SURCHRG FINE $750 04 ARRESTED/TAKEN INTO CUSTODY 19920116 AGENCY: XA0520100 CORALVILLE PD CHARGE NO- 02 IA STATUTE IA706-2-2 -2-ASSAULT CAUSE INJURY TRK#: L39989002 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA708-2-2 ASSAULT CAUSE INJURY CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L39989001 SENTENCE JAIL 120D 115D CREDIT OS ARRESTED/TAKEN INTO CUSTODY 19920116 A AGENCY: IA0520000 JOHNSON CO SO CHARGE NO- Ol IA STATUTE IA702-18 WILLFUL INJURY TRK#: L399891D1 COURT DISPOSITION AGENCY: TA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA708-2 ASSAULT WITH INT TO INFLICT SERIOUS INJURY CHARGE CLASS: MISDEMEANOR.CONVICTION TRK#: L39989101 SENTENCE PLEAD GUILTY 115D CREDIT JAIL 390D 06 ARRESTED/TAKEN INTO CUSTODY 19920705 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE TA321A-32 DRIVE W/REVOKED TRK#: L39989201 COURT DISPOSITION AGENCY: TAO52015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321-210 DCI 00421716 PAGE 2 OF 3 DISP EFF DAT 19920508 19920508 DISP EFF DAT 19920508 DISP EFF DAT 19920508 19920500 No. 8243 P. 3 CITYOFIC_CT TYC! ERK 2017 RPR 14 PH2:3 2 Aor•13. 2017 4:28PM Div of Criminal Investigation DRIVING WHILE RVKD CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: L39989201 SENTENCE FINE $50 PAY SURCHRG D7 ARRESTED/TAKEN INTO CUSTODY 19971007 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- D1 iA STATUTE IA124-401 FOSS SCHED I TRK#: 037284301 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA124-401(5) FOSS CONTR SUBS -BCH I-MARIJ CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 037284301 SENTENCE FINE $300 DCT 00421716 PAGE 3 OF 3 DISP EFF DAT 19921007 DISP EFF DAT 19980114 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY, DIVISION OF CRIMINAL INVESTIGATION No. 8243 P. 4 C2p11 APR 14 P 2.12