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Home My WebLink About17-074r IDENTIFICATION NO. —7— b�7 c t (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between B a.m. to 3 p.m., Monday— Friday) 410 East Washington Streel Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 3S6-5040 (319) 3S6-5497 FAX First Middle Last 1. Name (REQUIRED) 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email: ell Phone: (All written communication sent viae ail) 4a. Driver's License expiration date (REi b. Taxicab Business Name (REQUIRE[ 5. Prior experience in transportation of 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? LLn Type of offense Where When 7 F1 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Type of offense When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ Type of offense Where When o� 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please protiidd the7+ame(c}_ DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CiATIF1ED rn DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW 0 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 hereby certti that I have issued to me by the low e artment of Transport do a valid Driver's license number �.P�1kk � issued on -1 PIS expiring on 3 I1Z071J . I 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 appli tion, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all e times with all o p visions (A T�tle 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applin :�� Date S 1 1 1111f}HHflHHtlflHfMIHHHf!!f!ltlfllH11ff11fMHf!!flH1H1ffH1fM1HN1l1NHHNffINflN1NH1Hf}f!}HfffffNHlflffYffYff-fff!lflff STATE OF IOWA ) COUNTY OF JOHNSON ) Sbed and sworn to before me by S of v.c. �i P 1±P L - 1. E *A tc.A on this 1: day of M > 7,vi l 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 o7[ [l 4?4,2��` V_. , 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 MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. V Si ture of City Clerk or designee S1111Q Tte HHYHlffllHffYflf#1ff fHfffHHH1H}y.flfyf 1ffHiHHH1lH}H111111HHHffl11l11M1H1f-1'flH11fllHfY!!llfYflNNIfYlfflf!}11111{1f}fyrffi} N 0 Office Use Only a Approved application :4 C-) —j DCI report ;-t i rn State certified driving record 3 Website update n� CJe AXIDRNBADGEAPPLM1Ceme dtl DOC 072016 Asn.*a ,9. 2017 12:33PNbeb Divof Criminal Investigation y STATE OF IOWA Criminal. History Record Check is Request Form Tot Iowa Division of Criminal Investigation Support Operations Bureau, V Floor 215 L 7o Street Des Moines, IOWA 50319 (51g)'726.6666 I em reeuestins an Iowa Criminal HlstotvRecord Check en! (FAX)31933827A0. 8881 P. , 1,)2/002 DCT AccountNumber: _9967-F (If epplleable) From: Yellow Cab of Iown City PA Box 428 Iowa City, IA, 52244 Phonal Faxl (319)339-7302 Last Name mandslo First Name (msndsl Rlld die Name (tecammended) VN%-X�rKc J 0h b�!Swe z Date of Birth (mandolo ) Gender (mandatory) Socia Secus•I Number (W1nvnMded c)3-\ \- \, t15a -Mlls _tom ❑Male (Female m Waiverfnformalloni.. without a signed welvar from that subject of the request, a doinplete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For eamolete criminal history record Information, ss allowed bylaw, always obtain A waiver signature from the subject of the re uest. Waiver Reletuel t htmby poem alon for tho above mquoedng omolet to eandoat m Imp sdadnal blaoryiwmd cheek wllh the Division of Comlml Inveolge(lonPCI);myellmina shorty etWhir tothat bmdmalnneedbbyt`haOClmay beMuted asdlowWby(aw. WalverSlgnah�e� rcI C1�24laJ�i�� As of it searoh of the provided name and data of birth revealed: No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, ACI # DCI initials DCI -77 (08/25/10) Received Time May. 4. 2017 1:48PVt No. 8597 (DCI uee only) .n N O J _tom m .n ,,II��- Iowa Department of Transportation Mae of Darer Services ((dl Free) LW-532-1121PO Ow 9204, Des Movies, lA 503D&9204 515-244 9124 -44wFAX 515-239 1837 Certified Abstract of Driving Record Inquiry Date: 5/4/2017 DL/ID #: Name: Haman, Bernadette Class: 8988182 Leigh Desiree VAL Address: 1001 CROSS PARK Audit #: 03/11/2020 AVE APT B None • CDL Med Status: Issue Date: City/State: IOWA CITY, IA Expiration Date: Cancelled Revoked 522404482 3/11/1982 03/10/2011 Endorsements: Mailing Address: 1001 CROSS PARK Restrictions: 02/23/2014 AVE APT B Habitual Suspended, Denied, Date of Birth: Mailing IOWA CITY, IA Sex: City/State: 522404482 c Convictions 553XX8770 (IA) Customer #: 1877535 C ID Status: EXP 8988182 DL Status: VAL 04/07/2015 CDL Status: None 03/11/2020 CDL Cert Status: None NONE CDL Med Status: None Corrective Lenses Restriction None Cancelled Revoked Supplement: 3/11/1982 03/10/2011 B20 F Johnson IA History Information Citation Date Conviction Date ACD Explanation County JUR 10/17/2007 12/19/2007 B20 Driving While Washington IA JUR • Suspended, Denied, 08/01/2012 W00 Unpaid College IA hka Cancelled Revoked 02/08/2011 03/10/2011 B20 Driving While Johnson IA 02/23/2014 W01 Habitual Suspended, Denied, Cancelled Revoked s•� c 12/09/2011 01/13/2012 520 Driving While Johnson IA Suspended, Denied, Cancelled Revoked Sanctions Type Effective End ACD Explanation Occurrence JUR 1r1 ;n Name: Haman, Bernadette Leigh Desiree DL/ID: 553XX8770 nc N JUR Suspended 01/07/2011 08/01/2012 W00 Unpaid College IA hka Loans Barred 02/25/2012 02/23/2014 W01 Habitual IA Offender s•� c 1r1 ;n Name: Haman, Bernadette Leigh Desiree DL/ID: 553XX8770 nc N 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: 5/4/2017 N. Q. O.T.: �•nw�.� Office of Driver Services Iowa Department of Transporation Name: Haman, Bernadette Leigh Desiree DL/ID: 553XX8770 N n L� .I C% 4 M