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Home My WebLink About17-0711 3 CITY OF IOWA CITY 410 East Washington Street Iowa city, Iowa 52240-1826 (319) 356-5040 (319) 3S6-5497 FAX IDENTIFICATION NO.1 —7-D Z 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 1. Name (REQUIRED) _ 2. Address (REQUIRED) S 3. Contact Information (REQUIRED) Email: ITT — % ',j Cell Phone: 5-43 tP/ 31-96 (All written communicati6n sent via email) 4a. Driver's License expiration date (REQUIRED) 7L rAi zz sK 3—R b. Taxicab Business Name (REQUIRED)(l�o(t/ / 0416 5. Prior experience in transportation of passengers: 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /V6 Type 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? A) D 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 years? /0 Type of offense Where When N 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pr*oq theziliame(a). /V DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT�.mTIFIED r DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE INE R 91EW� You must apply for an individual Department of Criminal Investigation Report (form available upoNn requ�, t). 0 (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APF ICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify hat have issued to me by the Iowa Department of Transportation a valid Driver's license number 71 7�/,5 issued on 1 -i0 -O expiring on ` ::Iq- /g 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 applic do d I f her agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions,�Cter 2, of the City Code. (Needs to be signed in front of a Notary Public) t Signature of Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) .Subscribed and sworn to before me by `KbN%!s ��\a„ \—v e e �. o;v �v , on this t day of in and for the 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_c�jowa CA (Title 5, Chapter 2, City Code). or 211 / 6 Y H v D to 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. Signa f City Clerk'or designee' �n Date Office Use Only Approved application DCI report , State certified driving record o Website update � M Cledc/rAXIDRIVRADGE PPL92014eme ded.Doc N 07/2016 b _ OvM�. 1.. 2017)1 1:48PMoebtDiv of Criminal Investigation STATE OF IOWA Criminal History Record Check 0) Request Form To: Iowa Division of Crlmlual Investigation Support Operations Bureau, I" Floor 215 R. I" Street Des Molnes, Iowa 50319 (SIS) 725.6066 (515) 725-6080 Fax I em reouestine an Iowa Criminal Filernry 11eeAret rk..ele n.v (FAX)31933827No. 8289 P• 11'002 DC] Account Number: 9967-F (Irappileeble) From: Yellow Cab of Iowa City P.O. Box 428 Iowa City, T.A. 52244 (319) 338-9777 phone, Fox; (319) 339-7302 l Last Name (mandeuna First Name mendaloLw Middle Name (rcoommeoacd) rd�l, �/ �z C) A // rte Date of Birth (mauaelo ) Gender mandmo Social Securrl Number resanmonde 4ale ❑Female 5 Tl — p I37aiver InforMafion: Without a signed waiver &am the subject of the request, a complete crlmitlsl history record may not be releasable, per Coda of Iowa, Chapter6912. Fol, complete criminal history record Information, as allowed bylaw, always obtain v Iva signature from the sub est of (he request, Waiver Release; I he(eby give pe,ml %Ion tos aha Wove requesting oplolal duce an Iowa edmloal binoty record oheok wlth the Dlvldon orCriminal Investitetion(DC)).Any otiminst hluory date con" mina me that l rel eased as allowed by law, Wal ver Signature: Iowa Crimi a -Histo Record Check Results aardy) Aa of a search of the provided neuro and date of birth revealed:' a — �-- 0 No Iowa Criminal History Record found with DCI r q M N. ❑ Iowa Criminal istory Record attached, DCI 4 +- ca DCl initl o—SAff DCI -77 (08/25/10) Received Time Apr.27, 2017 12:16PM No.U20 /� Iowa Department of Transportation pp Office of Direr Services {Toll Freel 6D0-532-1121 PO Box 9204, Des 61MM, 1A50306.9204 5154449124 4" FAX- 515239.1837 CLEAR DRIVING RECORD Name: Freedain, John Allen JR DL/ID: 765A]6658 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: 7 tL{�� 4/27/2017 -'—' 10 D. 0. T. t Office of Driver Services 'Co Iowa Department of Transporation --� Name: Freedain, John Allen JR DL/ID: 765AJ6658 Certified Abstract of Driving Record Inquiry Date: 4/27/2017 DL/ID #: 765AJ6658 (IA) Customer #: 5781454 Name: Freedain, John Allen Class: C ID Status: None JR Address: 107 HUTCHINSON Audit #: 1539342 DL Status: VAL ST Issue Date: 01/10/2017 CDL Status: None City/State: HARPER, IA Expiration Date: 03/19/2018 CDL Cert Status: None 522318703 Endorsements: L CDL Med Status: None Mailing Address: 107 HUTCHINSON Restrictions: Corrective Lenses, Restriction None ST Left and Right Supplement: Outside Mirrors, Left Outside Mirror Date of Birth: 3/19/1968 Mailing HARPER, IA Sex: M City/State: 522318703 History Information CLEAR DRIVING RECORD Name: Freedain, John Allen JR DL/ID: 765A]6658 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: 7 tL{�� 4/27/2017 -'—' 10 D. 0. T. t Office of Driver Services 'Co Iowa Department of Transporation --� Name: Freedain, John Allen JR DL/ID: 765AJ6658