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Home My WebLink About17-142�r CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 5 22 40- 1 826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. / '7 — I L1 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 Last 2. Address (REQUIRED) IN2Q k P.LwnoD cT 3. Contact Information (REQUIRED) Email: Cell Phone: 3143�O�LZ/o (All written communica Ion sent via email) 4a. Driver's License expiration date (REQUIRED) r% -Z 3 -Zo Z a b. Taxicab Business Name (REQUIRED) �2tt.ow� C-0 B 6F xcwrq az ry 5. Prior experience in transportation of passengers: tcY4 A 12S 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? IJ i7 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? t.i 1l4 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 chauffeurs license been suspended or revoked in the last five years? N I gr Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please Oovjdethe narll�y c� po DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATtr-CERTII DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C' HIEF�M You must apply for an individual Department of Criminal Investigation Report (form available on req st). (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 432- 4 14 5-7n7 issued on lo-tj- Ito expiring on q-23-zo . 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 provielons of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant ��IWk Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscri ed and sworn to before me by lH*4—' )L on this 17— day of 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 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. Signa re of City Cler r designee -/0/-)-//7 Date v_J flffffflffff4filLftYlt�flf�f�ffftlf-fitfiTf lf.�Hff�aft�fltfltflff-�tf�a��afM��f �� J CD 1 Office Use Only Approved application DCI report State certified driving record Website update GeWTAXIDRMLADGEAPPL920148 de .DDC 07/2016 "�C— f •1 cn .-13 GeWTAXIDRMLADGEAPPL920148 de .DDC 07/2016 AC Iowa Department of Transportation C%doe of 0"M 9erwccs ( toll Free) NO 532 1121 PO Box 9204, Des Manes, IA 503453204 515-244-9124 FAX- 515 239"1831 CLEAR DRIVING RECORD Name: Prymek, Donna Marie DL/ID: 432YY5707 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: IOWA D. 0. T. Name: Prymek, Donna Marie DL/ID: 432YY5707 9/25/2017 i a s Office of Driver Services Iowa Department of Transporation ,v 0 C7 O �>- 4�i n q rn , Ji Certified Abstract of Driving Record Inquiry Date: 9/25/2017 DL/ID #: 432YY5707(IA) Customer #: 3875157 Name: Prymek, Donna Class: D ID Status: None Marie Address: 1129 KIRKWOOD CT Audit #: 1373342 DL Status: VAL Issue Date: 10/18/2016 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 09/23/2020 CDL Cert Status: None 522405772 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: 1129 KIRKWOOD CT Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 09/23/1979 Mailing IOWA CITY, IA Sex: F City/State: 522405772 History Information CLEAR DRIVING RECORD Name: Prymek, Donna Marie DL/ID: 432YY5707 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: IOWA D. 0. T. Name: Prymek, Donna Marie DL/ID: 432YY5707 9/25/2017 i a s Office of Driver Services Iowa Department of Transporation ,v 0 C7 O �>- 4�i n q rn , Ji NATE OF IOWA 0 Criminal History Record Check: Request Form To: Iowa Division of Criminal Investigation Support operations Bureau, I" Floor 215 E.7" Street Des Molues, Iowa $0319 (525) 725.6066 `( VtiL,� -Z3 . `- r UL1L;' "I - ACI Account Number: 9967_F �� (if applicable) From: Yellow Cab of Iowa City P.O. Box 42S Iowa City, IA. 52244 Phone: Fax: (319) 339-7302 ❑Male 9fe-tnale I q � 9 ` ()(L)' (cS 11,0 Waiver11 forntofion- Without a signed waiver from the subject of the request, a complete criminal history record may nat be releasable, per. Code of Iowa, Chapter 692.2. For et criminal history record information, as allowed bylaw, always ebtain a waiversl¢nature Yram the subject orthe renueer Waiver 1?e1eaSe;1 hereby glvc pe.^,niJblon for T above requesting onlclel m conduci m lotra ctiminal blstory,e mrd check with the Division ofCtirolml envesllgstlon (pCq; Any criminal history data concerning mo thm is meintelned DCI may be rolenscd as allowed by law. Waiver, Signature; (DCI use only) As of a search of the provided name: and date of birth revealed; No Iowa Criminal History Record found with DCT :v o - Iowa Criminal History Record attached, DCI = ^' DCI initials -- DCI-77 (08/25/10) ecves l ime a_p.25, 2017 9:5641 No. 1553