HomeMy WebLinkAbout17-158% r IDENTIFICATION NOJ ] — / 5F�)
(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
(3 19) 356-5040
(319) 3S6-5497 FAX
First
1. Name (REQUIRED) .
2. Address (REQUIRED)
Middle
3. Contact Information (REQUIRED) Email:j7t/�j7i�rc oma,; eiP, �Lr,l,rr9 e A, f Cell Phone: -25
(AII written communication sen is email)}°�lti�.
4a. Driver's License expiration date (REQUIRED) —0 /— E<2/ '!
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? f+�
Tvoe of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? Az//Y
Tvoe of offense Where When
What happened to the charge? (Circle one)
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? /nl rY
Tvoe of offense Where When
0
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, pleasaX6Dldege name
Z;
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STE FIE
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICEy EVIF�[_'
You must apply for an individual Department of Criminal Investigation Report (form aVMlablepjon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have Is 4ed to me by the Iowa Dep rtment jojfTransportation a valid Driver's license number
�� rn o &lz46sued on �Y� ng on 1,E ! �� understand that 'rf I
ffdlsely aFFflllswer any questions in this plication, that this application a 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, ff authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5, Chapter 2, f 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 1.15 r t tAol ', P, �- ))tj [2qa ttP on this 229 day of
vacJ. Zot_7 . ,i,A -
4jtj WENDY S. MAYER g'` � - dA
Comm=on Numw 7204281 Notary Public in M4 for the State oflowa
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 thgelty of Iowa City (Title 5, Chapter 2, City Code).
license i e / �I
or
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.
/2q/%
Signature of City Clerk# designee Date
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Office Use Only 3> __4 ^�
Approved application
3
DCI report o to
State certified driving record
Website update 3>�,�
GskirnXIDRNIAWEAPPL92014a�dtl DOC 07/2016
r
CIowa Department of Transportation
AW ofGoe of Dram sr -races (Toll Free) WO -532-1121
PO BOX 92134, Deg MOIDOS. IA 50306-9204 5155-244-&124
FAX: 515.239.1937
Certified Abstract of Driving Record
Inquiry Date:
11/16/2017
DL/ID #:
Name:
Phllogene, Widmaler Class:
Address:
927 BOSTON WAV
Audit #:
VAL
APT 12
CDL Status:
None
12/01/2019
Issue Date:
City/State:
CORALVILLE, IA
Expiration Date:
Interstate
522413159
CDL Med Status:
Certified
SR Required
Endorsements:
Mailing Address:
PO BOX 5552
Restrictions:
12/01/1983
Date of Birth:
Mailing
CORALVILLE, IA
Sex:
City/State:
522410552
CDL Medical Examiner's Certificate
787AK0765 (IA)
Customer #:
5608287
C
ID Status:
VAL
1768818
DL Status:
VAL
04/25/2017
CDL Status:
None
12/01/2019
CDL Cert Status:
Non -Excepted
Medical Examiner Type
Medical Doctor
Interstate
NONE
CDL Med Status:
Certified
SR Required
Restriction
None
Supplement:
12/01/1983
M
Certificate Specifics
Explanations
Medical Examiner First Name
Ran
Medical Examiner Middle Name
Matthew
Medical Examiner Last Name
Dowden
Medical Examiner License Number
35434
9565950912
Medical Examiner National Registry Number
Medical Examiner Jurisdiction
IA
Medical Examiner Phone
319 369-7211
Medical Examiner Type
Medical Doctor
Medical Certificate Issued Date
09/01/2015
Medical Certificate Expiration Date
09/01/2017
Date Added to CDUS Driving Record
03/12/2016
History Information
Convictions
Citation Date
a
J
J
say
Coun
03/11/2014
—��
n 1
Citation Date
Conviction Date
ACD
Explanation
Coun
03/11/2014
04/04/2014
B51
No Drivers License
Muscatine
03/1 2014
04/04/2014
B64
No Insurance Card
Muscatine IA
03/05/2015
04/16/2015
S93
Seed
Johnson IA w
Sanctions
Type
Effective
End
ACD
Explanation
Occurrence
JUR
N
cD
Pte'
i
JUR
w
Suspended
11/07/2014
11/25/2014
D53
Non -Payment of
IA
U1
Iowa Flne
Suspended
06/30/2016
07/29/2016
M75
Serious Violation
IA
IA
Name: Philogene, Widmaier DL/ID: 787AK0765
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: Philogene, Widmaier DL/ID: 787AK0765
11/16/2017
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Office of Driver Services
Iowa Department of Transporation
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- Nov. 17. 2017 10:56AM Div of Criminal Investigation
11/16/2017 13:06Yellow Cab of Iowa City
STATE OF IOWA
Criminal History Record Check
is Request Form
To: Iowa lllvltlon of Criminal Inveatlgntion
Support Operations Bureau, 1" Floor
215 E. 7i° Street
Der Molnes, Iowa 60319
(515)725-6066
(M) 725-6000 Fax
I am reauestlna an Iowa.Crim [no I History Record Check on:
No. 6624 P. 1/3
(Fpx)31937e2709 P.002/003
DC1 A000untNumber: _9967-F
(if Applicable)
From: Yellow Cab or Iowa Clty
P.O. Box 428
Iowa City, IA. 52244
(319) 338-9777
Phonet
Baxi (319) 339-7302
LaO Name(mandatory)
First Name mendmo
Middle Nome rteommended .
.ty�
ae'
y�, /MCLAfpp-
Date of Birth (manduopry)P
Gander mondato
Soolal SecurityNumber (,ecommmded
/a -o 7— / d 63.
I
am
le ElFeale
)yglverinfarmallond Without a signed walver from the subject or:ho request I a domplete orlminel history record may not
he releasable, per Code of Iowa, Chapter 692.2. For complete erlmlitdi history record Information, ag allowed bylaw, always
obtain a waivtrilliiiatura from the subject orthe re umf.
Walver Release;1 hercby give pennlsslon foi vte Above regucsllns ofnolel to conduct as 1Qm anminal Dlrlaton er UMM
Inveldgadon (OCI),. Any w1 ntnal hinorydale conotming me thM 11 mdntalned by )ho l7Cl may bo rolseaed u allowed by Imv.
Wa1varS1gnafnre
Iowa Criminal History Record Check Results
As of 1 ' )~7-17 a search of the provided name and date of birth revagled;
Me
o Iowa Crimfned History Record found with DCI fit. ,
cs:•
11 Iowa Criminal Hi9tory Record attached, DCI #
DCI initials
DCI -77 (08/25/10)
a ... :—A T;... tl... 16 W17 1. 100II, A107
(nCJ use only)
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