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Home My WebLink About17-087r CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) . IDENTIFICATION NO. -7-0? -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 Middle 2. Address (REQUIRED) 514 5 LuroLS 9-L -Troon k t r rr�ulc s2-740 3. Contact Information (REQUIRED) Email: (�C._(?utto>19kcirid.[i)ry+1�cL.,cnM CellPhone:(3t9)Sg1 -171(a (All written commun tion sent via email) 4a. Driver's License expiration date (REQUIRED) To. YCuC1 " 2 j> 3 22L b. Taxicab Business Name (REQUIRED) Hoak L, Dab 5. Prior experience in transportation of passengers U5T - A`CO./Q Ekt r)+u •ilLr�r�d C� E, m(- t.)bQva {.VAca. t.)Qc a�Cl9SQC1CZ�lCS 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? qu—s Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead 1Guilty Othe to do 44krs 7. Have you been arrested/ charged with any traffic offenses in the last five years? ISO b r� n` 3¢2EVk(:9 Type of offense Where Whence What happened to the charge? (Circle one) :zi C-) m 1Z-1 �rn n m Convicted Dismissed Deferred Suspended Plead GuilF)�th? 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? & Tvoe of offense Where Whenra 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 i 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 10:7 A1-.•1 1 0 2_9 issued on 2 -24- 17 expiring on s. 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 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) STATE OF IOWA ) COUNTY OF JOHNSON ) §ubscribed and sworn to before me by A%A 5k a .a un K• uc� )1i n••- :� on this day of . 0 -7 7 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). or designee e2 dl /� I 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. Signature of City Clerk I esignee Date +wxx+xxxxx++++++++++++++++++++++++++++xx++xxx+++xxx+xxxxxxxx+xxxxx+xxx++++x++xx++++++++x++++++++++++++++++++++++++++»++++++x++x+xxx++xx+++x+xx+ Office Use Only N Approved application A� L DCI report at x State certified driving record c�-< Website update =�rri ; m d� o C.) GerkrrMIDRIVBADGE PL92016amended.DOC 07/2016 Icu. J. LV II J•'tJlIn ulv uI V111111llal lAuvcar Isar lull Frem:CteY Or IOWA CITY clerk O,Me 37P 3I66669Y ST) Criminal I ". L)LV I. 11 01/31/2017 11:27 iAB12 P.002/002 TE OF IOWA istory Record Check equest Form, To: Iowa Division of Criminal Invesligation support Operations Bureau, V Floor 215 R. 7" Street Des Moines, lows 50319 (515)725-6066 (515) 725-6000 Nair I am requesting an Iowa Criminal History Record Cheek nii- DCI Account Number, i400 l-)- – F (irepplicabic) From: 0w of lows City City Cleric's office 410 D. Washington Stt tet Iowa City, IA 52240 Phone: 319356-5041 Fax: 319356-5497 Last Name (mandatory) First Na a (mandator)) Middle Name (recommended) nit CLv;C: rILAC.. ILvrflo.Litl. Date of Birth Wandatory) CxeIIder (m ndatory) Social SecurityNumber (recommended) Fab 7,3 1 g al l OMA a LlFemale 314r DIT 34-53 Waiver. Injornration: Wi(hout a signed waiver from he subject of the request, a complete criminal history record may nal be releasable, per Code of lows, Chapter 692.2. For comolete criminal history record information, as allowed by taw, always obtain a waivers/ nature from the stlbieetofthe re ue}l. i Waiver Release: I hereby sive permission for the above requesting official to conduct an Iowa criminal history record check Milli the Division ofCrimhsal LFvassianlion (DCI). Any cimlnal history dataeoaccasing ma 11101. is maintained by We DCl maybe released as allowed by law. ' Waiver Signature: lam— I As of �a V�) � % 7 , a search of the No Iowa Criminal History Record f ❑ Iowa Criminal History Record DCI initials - DCI -77 (08/25/10) n --- :__-J T:_. 1__ 9, 4n11 1A_IAAIA n_ nrAn """•"' (DCI me only) h. r. I name and date of birth revealed: r I with DCI — DCI # a co 1 Iowa Department of Transportation i 0 Office of Drives Services (Toll free) MD -532.1121 PO 6Dx 9204, Des Moines, fA 5MD6-92(14 515-244-9124 FAX --515.239-1837 Certified Abstract of Driving Record Inquiry Date: 1/30/2017 DL/ID #: Name: McWilliams, Class: 1126182 Aushenna Kornelia SUR Address: 3750 16TH AVE SW Audit #: 02/23/2024 CDL Cert Status: Issue Date: City/State: CEDAR RAPIDS, IA Expiration Date: NONE 524042301 Certified Corrective Lenses Restriction Endorsements: Mailing Address: 1571 CHASE ST Restrictions: 2/23/1991 Date of Birth: Mailing GARY, IN Sex: City/State: 464042021 CDL Medical Examiner's Certificate 107AM1029 (IA) Customer #: 6504393 A ID Status: None 1126182 DL Status: SUR 07/05/2016 CDL Status: SUR 02/23/2024 CDL Cert Status: Non -Excepted 319 369-8153 Medical Examiner Type Interstate NONE CDL Med Status: Certified Corrective Lenses Restriction None Date Added to CDLIS Driving Record Supplement: 2/23/1991 F Certificate Specifics Explanations Medical Examiner First Name Joshua Medical Examiner Middle Name Allen Medical Examiner Last Name Pruitt Medical Examiner License Number 38567 Medical Examiner National Registry Number 9274182852 Medical Examiner Jurisdiction IA Medical Examiner Phone 319 369-8153 Medical Examiner Type Medical Doctor Medical Certificate Restriction 1 Wearing corrective lenses Medical Certificate Issued Date 06/06/2016 Medical Certificate Expiration Date 06/06/2018 Date Added to CDLIS Driving Record 07/05/2016 History Information CLEAR DRIVING RECORD Name: McWilliams, Aushenna Komelia DL/ID: 107AM1029 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: 1141 1/30/2017 IOWA * �As, ` D. 0. T.: • Office of Driver Services Iowa Department of Transporation Name: McWilliams, Aushenna Kornelia DL/ID: 107AM1029 1/30/2017 myBM V - Indiana Bureau of Motor Vehicles myaMv Plates And Vehicle Licenses Driver Suspension& my CLP Endorsements: Homo Registrations Titles And to Cards Records Reinstatement Information 38567 Medical Examiners FMCSA National Registry Number. 9274182852 FMCSA Medical Exemption Effective Date: Convictions — (' indicates active points) FMCSA Medical Exemption Expiration Date: Disposition Offense Offense FMCSA Skills Performance Evaluation Effective Date: Sign Out my Driver Records View Your Driver Record Official Driver Record Pay Reinstatement Fees Online Renew Your License or ID Card View Your Recent Driver Notices Track Your Recent Renewals Replacement Licenses or IDs Schedule Driving Test Your Renewal Dale CDL Self -Certify Driver Type Proceed to Checkout Click to Verily - This site chose VeriSign SSL for secure e- commerce and confidential communications. Norton'; 11 SyMaMec SECOR�D . t•eovi SSL cFanrrurEs my Driver Records Welcome, AUSHENNA KORNELIA MC WILLIAMSI ?Be Loading your driving record... **NOTE: The BMV only retains supporting documentation for a period often (10) years" License status: VALID As of 01/30/2017 5:13 pm IINT Current points: 0 Commercial Driver License (CDL) Information: CDL Status: Valid CDL Expires: 02/2312021 CDL Endorsements: CDL Class: A CDL Restrictions: B Commercial Learner Permit (CLP) Information: CLP Expires: CLP Endorsements: CLP Class: CLP Restrictions: None CDUS Status: UC MD Self -Certification Status: Interstate - Non -Excepted IA Medical Certificate Status: Certified 38567 Medical Examiner's Certificate Information Medical Certificate Issue Dale: 05/06/2016 Medical Certificate Expire Dale: 0610612018 Medical Certificate Restriction Codes: Medical Examiners Name: JOSHUA PRUITT Medical Examiners Phone Number. 3193697105 Medical Examiners Speciality Code: MD Medical Examiners Jurisdiction: IA Medical Examiners Jurisdiction License Number. 38567 Medical Examiners FMCSA National Registry Number. 9274182852 FMCSA Medical Exemption Effective Date: Convictions — (' indicates active points) FMCSA Medical Exemption Expiration Date: Disposition Offense Offense FMCSA Skills Performance Evaluation Effective Date: Date pts Description Dale FMCSA Skills Performance Evaluation Expiration Date: 05/20/2013 0 SEAT BELT VIOLATION 03119/2013 Suspension Information — (• indicates active suspensions) No Suspensions were found. Pending Suspension Information No Pending Suspensions were found. Disqualification Information — (' indicates active disqualifications) No Disqualifications were found. Pending Disqualification Information No Pending Disqualifications were found. Out of State Withdrawal Information No OOS Withdrawals were found. Convictions — (' indicates active points) Disposition Offense Offense Susp Disq Date pts Description Dale Court / Case Number IDs IDs 05/20/2013 0 SEAT BELT VIOLATION 03119/2013 LAKE SUP DIVISION #4! 45D12130311`01352 03/20/2013 0 SEAT BELT VIOLATION 01117/2013 LAKE SUPERIOR #7 / hUpsl/secure.in.gov/BMV/mybmv/MyDriver/DriverRecord.aspx 118 1/30/2017 mybmv- inaiana oureeu or mural vnin��ca vawr wv urwroa 03/07/2013 0 SEAT BELT VIOLATION 01/08/2013 ELH 0OD CI E 001517 Mailing Addresses m Effective Street Date Address City Slate ZIP Code 3 08/24/2016 1571 CHASE ST GARY IN 464042021 2 07/17/2012 7138ASH AVE GARY IN 46403-2017 1 05/12/2009 713 W 35TH AVE APT GARY IN 46408-1555 Legal Addresses ID Effective Date Street Address City State ZIP Cade 3 08/24/2016 1571 CHASE ST GARY IN 46404-2021 2 07/17/2012 7138 ASH AVE GARY IN 46403-2017 1 05/12/2009 713 W 35TH AVE APT GARY IN 46406-1555 Credential Issuance Interim Credential Issue Date: 8/24/2016, Expiration Date: 912312016, Reason: NEW ISSUE DL, OUT-OF-STATE, Control it. 9355063 Issue Date: 08/2412016, Issue CDL, CDL CLASS A, Endorsements: None, Restrictions: B. Expiration Date: 02/23/2021 Interim Credential Issue Date: 4/112015, Expiration Date: 511/2015, Reason: RENEWAL DL W/O CARD, INSTATE, Control #: 7096947 Issue Date: 04/0112015, Renew License, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 06/27/2016 Interim Credential Issue Date. 312712015, Expiration Date: 4126/2015, Reason: RENEWAL ID W10 CARD, INSTATE, Control M 7082109 Issue Date: 03127/2015, Renew 10 Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date: 04/01/2015 Interim Credential Issue Date: 7/2312013, Expiration Date: 812212013, Reason: DUPLICATE DL, IN-STATE, Control 4951377 Issue Date: 0712312013, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/27/2015 httpsl/secure.imgovBMV/mybmv/MyDriver/DriverRecord.aspx 218 1130/2017 myCM V - InOrana cm eau onvwr, vei uww uneum �,reumniai issue vane. a urcu i<, upnauun gram. or rarcu �q neasuu. mm�v� ��vwv �.nnv, uv -o rni c, Control #: 3146532 ° Issue Date: 07/17/2012, Amend License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/2712015 Interim Credential Issue Date: 5/2512012, Expiration Date: 6/2412012, Reason: DUPLICATE DL, IN-STATE, Control #: 286340D — Issue Dale: 05125/2012, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/2712015 —_ Interim Credential Issue Date: 1126/2010, Expiration Date: 2/9/2010, Reason: DUPLICATE DL, INSTATE, Control #: 228853 Issue Date: 01126/2010, Duplicate License, OPERATOR, Endorsements: None, Restrictions: B, Expiration Date: 03/27/2015 Issue Date: 09/02/2009, Issue Operator, OPERATOR, Endorsements: None, Restrictions: B. Expiration Date: 03/27/2015 Issue Date: 05122/2009, Renew Permit, LEARNER PERMIT, Endorsements: None, Restrictions: B, Expiration Date: 05/31/2010 Issue Date: 05112/2009, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date: 05/2212009 Issue Date: 10/05/2007, Issue Learner, LEARNER PERMIT, Endorsements: None, Restrictions: B, Expiration Date: 10/31/2008 _ ____--- Issue Date: 08/10/2004, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 10/05/2007 _ Issue Date: 04105/2003, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 04/30/2007 Issue Date: 03/0411999, Renew ID Card, REGULAR ID CARD, Endorsements: None, Restrictions: None, Expiration Date 0313112003 Remarks Remark Date:06/1112016 Moved to IA 160611 Remade Date:04101/2015 ID Card voluntarily surrendered on: 4/112015 10:48:43 AM Remark Date:03127/2015 License voluntarily surrendered on: 3/27/2015 5:16:17 PM Remark Date:05/2212009 ID Card voluntarily surrendered on: 5/22/2009 3:44:33 PM Remark Date:10/05/2007 License voluntarily surrendered on: 10/512007 3:24:00 PM ................,.«,..«.... End of Driver Record ' https://secure.in.gov/BMV/mybmv/MyDriver/DriverRecord.aspx 318