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Home My WebLink About17-078' IDENTIFICATION NO. 1-7 -072S r 1 (Office Use Only) CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (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 (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) 0 E ry w t S r WAR 1{ S "h J rn o rxt 2. Address (REQUIRED) a- (5 1 F�—V;,L !4 ,-,K) 3. Contact Information (REQUIRED) Email: YhGQ5tr cr 4F604 QMG(d,60111 Cell Phone: '1 S/h- 6221 (All written communica lon sent via email) 4a. Driver's License expiration date (REQUIRED) 4 LI S T(D b. Taxicab Business Name (REQUIRED) 'I �Z L o to 5. Prior experience in transportation of passengers: r,jM�,� i I--,6.� 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere (Aq Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. 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? D Tvoe of offense Where 9. Have you ever applied to be`rann^)Iowa City taxi driver using a different name? If yes, please provtdep thgame sWl- 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 q u�u s a Imz� \ issued on expiring on a I understand that if I falsely answer any questions in this application, that this appli atio may be denied. II dgrebaking 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 provisignkof Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant ht� 1 ' `� V Date �-)14 rl STATE OF IOWA ) COUNTY OF JOHNSON ) and sworn to before me by S 1_:)l _v-v�_0YL';f on this 194-L day of Public in and forrft 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). license _lilt fi ll2, 0 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. 'Sigoat e of City Jerk or esig—ii nee SAI\ 9 \ \--1 Date N a t � Office Use Only j n `a Approved application rn Fin DCI report State certified driving record ca Website update Cled,/rAXIDRN64DGEAPPL92014em.dW.DOC 07/2016 PA oVApr. 10. 20170 9:500 cab Div of Criminal Investigation STATE OF IOW Criminal History. Recor Check Request Form To: Iowa 1)Ivlslon of Criminal Investigation Support Operations Bureau, V Moor 215 X. 711 $beat Des Moines, Iowa 90319 (516)725.6066 (515)726.6080 Fax I can raguestinar an loiYA rriminal Histo Rocord Check on: (FAX)3193382-No. 7830 P. 11/002 DCI ceountNumber: 99(7-F Frim. ygllowCab ofIowa City Y.O. Box 428 Iowa City, IA, $2244 (319) 338.9777 'Pb Inet (319) 339+7302 Last Name mmutai First Name (mpnditoM (ocl usaunly) Middle Nume (reaommended) . 9D vmonrr• lDCP--rivI PNo Iowa Criminal History Record found with DCI 0-14A(zL&S Date of Birth mmdge Galader (mendoto) 'Social �SOQUMY Number meommeeded) ° lmale ❑Femal G:3 ti — 3Z - Y 2 s", WaiverXf(formafl0nr Without aslgned Nvalver from the subject of the rat uest, a domplete crtminei history record may not be releasable, pet Code'oflowa, Choplor 692,2. For y m�oiala eriminel histo y record lafeimatlon; ss ellawad bylaw, always obtain a waiver a from the sub act of iha re uest.. M71verRe%ase:lhercbY6Wcpermiselon1byMeabove nquesdngonlelsltoconduct onlosv i MOW hutorynourdcheck srhhNo0helslonoferirolrud Invanlr.tion(OCI), Any odmbalhinoryda coneemin6 a IlsmelnilnodbytheOel leeeedmdlowedbylnv. I�afYer.ifgtfafArei 'Iowa Criminal History Record Check liesults (ocl usaunly) As of `� `1 a search of the provided name end d to of birth revealed: ry-• PNo Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, DCI k 7 _ .. ° ACT Initials s DOM (08125110) Received Time Apr. 6. 2017 11:22AM No. 7570 LAIIowa Department of Transportation B`fiIce Df Driyu 515-244.3124 Pt) Bac 9204, EM Minus, 1A 5030&9204 PAY: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 4/6/2017 DL/ID #: Name. Dumont, Dennis Class: Charles Address: 2491 HOLIDAY RD Audit #: Issue Date: City/State: CORAL-VILLE, IA Expiration Date: 522414705 Endorsements: Mailing Address: 2491 HOLIDAY RD Restrictions: Mailing City/State: Date of Birth: CORALVILLE, IA Sex: 522414705 445AF9612 (IA) customer #: 5722274 D ID Status: None 1707445 DL Status: VAL 03/28/2017 CDL Status: None 11/11/2020 LDL Cert Status: None 3 CDL Med Status: None Corrective Lenses, Restriction None Left and Right Supplement: Outside MirLeft Outside Mirror 11/11/1945 M History Information CLEAR DRIVING RECORD Name: Dumont, Dennis Charles DL/ID: 44SAF9612 Pursuant to Iowa Code 4321.10, 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 e, and that I have been authorized by the Director of the Iowa Department an official record currently in the custody of said Offic 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: Dumont, Dennis Charles DL/ID: 445AF9612 4/6/2017 ti Office of Driver Services Iowa Department of Transporation