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Home My WebLink About17-126CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. 1-7 —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 s5 Last w I/ . 3. Contact Information (REQUIRED) Email: 5 *^ 4 / ee P 4 +A / t` /.,... Cell Phone: 3/1 0 b11720 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) t O 71t b. Taxicab Business Name (REQUIRED) t " 1 5. Prior experience in transportation of passengers: S v + •• b 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Where What happened to the charge? (Circle one) When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? k 4 , Type of offense 0 t_-ff.L LaH'� Where When What happened to the charge? (Circle one) c,D -� \-:.» _ i Convicted Dismissed Deferred Suspended Plead.Guilty''--Qthe- F rsq a O�— 8. Has your driver's license or chauffeurs license been suspended or revoked in the last five yea r r— Type of offense Where Q 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) L.« l^/, 11 r' -M (^ "kur: .....1 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 -.� f APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereb certify that I have issued to me by the Iowa De art. ent of Transportation a valid Driver's license number 77� U Y Y U (� i issued on 9 21 5 expiring on D 7(ti�2 L I understand that rf I falsely answe an q estions 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 Applicant Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by 1-.« XU. W S "*'r -w mAr '),O l—J , t\ in and for on this (4 day of 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). 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. 9 Sighature of City Clei&br designee / Dab N O Office Use Only c� vt2 r7 Y _j r Approved application rn DCI report State certified driving record Website update Gerk/TAXIMIVBADGEAPPL92014art ded.DOC 07/2016 Aug. 17. 2017 9;19AM Div of Criminal Investigation No. 8393 P. 1/3 F,.m:Ciey or low. City Clerk Offlco 310 366a427 oa/1s/2017 16:10 .177 P.002/002 STATE OF IOWA /.. ., Clrinillnal History Record Check � v Reflttlest Form 5� DCII Aecounl Nimiber: _ L/ CG) '/—''-7 (ifapplicoLlej To: Iowa Division of Criminal lnveoigalion From; C1h� oF1olva Ci(y Support operations aureau, i" Floor City CICHL's Office — -- 215 E. 7" Street 4I0 F. Wasllin tog n Sfreet Des Moines, Iowa 50319(ellil 1719-9099 , (33 S) 725-6000 Fax — -- Phone: 319-356.5041 Fe a, 319.356-5497 T am reovestinc an Iowa Criminal Rktnry Ii PCOrrI f`henk nn - Last Naine (manaaiary) First Name (mandatory) Middle Name (nconwemded) Date of Birth (mandatory) Gender (mandatory) Social Secugrity Number ale ❑Female (ccoulmended) L I c7 / ' / S1" J Y/ v Waiver Information., Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2, For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of (he request. • IY4lve1' elea$e,^IVargadrglve pemasston for die a oro Rgiasimg omoiaf 10 condua en Iowa crimiwl history record cheap with iho Division of Criminal Investigation (ACO. Any criminal history data eonceming me shat is maintained by Ilia DCI may be rtlessed as allolscd by law. fYaiverSi�nalfae~J� Q Iowa Criminal I istory Record Check Results As of 8 " I - r ) % . a search of the provided name and date of high revealed: 0 No Iowa Criminal History Record found with DCI Iowa Criminal History Record attached, DCI 0 DCI initials DCI -77 (09/25110) s 1 4r AA41 A /.L nu n. /.A1C (0c) osc only) 0 i Iowa Department cif Transportation ! OThce of Orr&u SeiviDes (tcAl Fmc) L'{]t3 5321121 PO Sox, :72134, De.. Mims, IA 50306. 92,34 515-149-9124 FAX: 51239-1831 Inquiry Date: Name: Address: City/State: 8/25/2017 Willberg, Lee Marinus 1115 SAINT CLEMENTS ST IOWA CITY, IA 522456111 Mailing Address: 1115 SAINT CLEMENTS ST Mailing IOWA CITY, IA City/State: 522456111 Certified Abstract of Driving Record DL/ID #: 760YY4065 (IA) Class: B Audit #: 9360690 Issue Date: 08/21/2015 Expiration Date: 07/17/2022 Endorsements: NONE Restrictions: NONE Date of Birth: 07/17/1980 Sex: M CDL Medical Examiner's Certificate Customer #: 1827411 ID Status: EXP DL Status: VAL CDL Status: VAL CDL Cert Status: Non -Excepted Medical Examiner National Registry Number Interstate CDL Med Status: Not Certifed Restriction None Supplement: Medical Doctor Certificate Specifics Explanations Medical Examiner First Name Ernest Medical Examiner Middle Name Manuel Medical Examiner Last Name Perea Medical Examiner License Number 33079 Medical Examiner National Registry Number 3244024129 Medical Examiner Jurisdiction IA Medical Examiner Phone 319 339-3921 Medical Examiner Type Medical Doctor Medical Certificate Issued Date 07/10/2015 Medical Certificate Expiration Date 07/10/2017 Date Added to CDLIS Driving Record 08/21/2015 CDL Downgrades Effective End I Issuing JUR 09/08/2017 1 IA History Information Convictions Citation Date Conviction Date ACD Explanation countv ]UR 04/07/2011 04/07/2011 S92 Seed Johnson IA 08/04/2012 09/05/2012 M14 Fail to Obey Traffic Sign/Signal Johnson IA 02/12/2014 03/12/2014 M14 Fail to Obey Traffic Si n/Si nal Johnson IA Name: Willberg, Lee Marinus DL/ID: 760YY4065 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: 8/25/2017 f�t��I9r"ly �Pe 1 llip Office of Driver Services Iowa Department of Transporation Name: Willberg, Lee Marinus DL/ID: 760YY4065