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Home My WebLink About18-0020 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. 1 `5 - rJ rJZ (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 "reauired" information will result in denial of the application N FirstMiddle 1. Name (REQUIRED) �) E C2VYt / 1- p f \0.� ast �-, 2. Address (REQUIRED) �� /1� i C yt-o b 4 u c, lQ t --// C.ytcX S —QA- J527 3. Contact Information (REQUIRED) Email I e('evv�V koe 4vv,<0 („pp cn-Cell Phone: 3/9 -?9� - All writttent mmuni Ion sent via email) 4a. Driver's License expiration date (REQUIR D) I2Q(Z b. Taxicab Business Name (REQUIRED) e it Inc py C 5. Prior experience in transportation of passengers: lyr , 41 0 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this Stater else ere? Type of offense Where 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? e S Type of offense 1rivi= IR7T.1 91 What happened to the charge? (Circle one) ,-Convicted, Dismissed Deferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ✓� ��, Type of offense Where When 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 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 hereby certify'shat I have issued to me by the Iowa epa ment of Transporta'on valid Driver's license number ? 6 t 7 �7 Z 61 issued on I I ! %expiring on Z / . 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, ff authorization to be a taxicab driver is granted, to comply at all times with all of the provisio of Title 5, Chapter 2, pi the City Code. (Needs to be sig ed i front of a Notary Public) Signature of Applicant DateLy STATE OF IOWA ) "' COUNTY OF JOHNSON ) ✓' I Subscribed and sworn to before me by �Z• CMy� \SoQaw^ *� t day of ?13 1)` 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 4$j Signature of Police Chief or designee Date AFTERAPPROVAL 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. Sighature of City Cler"r designee Date #/ei'k'RNNM1f111f11MN1fe4li41fefMNlNfl111N11NIfN1f f4f f 1fflNNlflN!l1NlN11f11NlIf1f-f11111f!!!!11llflf-I 11NNNNlM#MINNNINllR11f! Office Use Only Approved application DCI report State certified driving record Website update GerWTAXIMN64DGEAP 02014amentl 00C 07/2016 pp 0�j� Iowa Departme M e of DlWw8ervk= Po Sox 9284, Deo Hautes, IA 5MD&92O4 nt of Transportation (Toll Free) 8W6n.1121 515.2444124 FAK 515.239.1837 History Information Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 1/3/2018 DL/ID #: 769YY3726 (IA) Customer #: 677799 Name: Koedam, Jeremy Class: D ID Status: None Jonas Address: 518 NICHOLS AVE Audit #: 1542972 DL Status: VAL Issue Date: 01/11/2017 CDL Status: None City/State: NICHOLS IA Expiration Date: 04/30/2021 CDL Cert Status: None 52766771 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: PO BOX 93 Restrictions: NONE Restriction None - Supplement: Date of Birth: 04/30/1982 Mailing NICHOLS, IA Sex: M City/State: 527660093 History Information Convictions Citation Date Conviction Date ACD Exlanatlon lCountv 3UR 07/16/2017 08/03/2017 M14 Fail to Obey Traffic Johnson Si n SI nal IA Name: Koedam, Jeremy Jonas DL/ID: 769YY3726 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: 1/3/2018 IOWA 1, 0. T .. Office of Driver Services --- Iowa Department of Transporation ti ovJan. 4. 20181, 9:18AMCab Div of Criminal Investigation STATE OF XOWA 0 Criminal History Record Check Request Form To: rows Division of Criminal Invallgatioh Support Operatlons bureau, 11" Floor 216 E. 7° 9traat Des Moines, Iowa 50319 (616)726.6066 (1116) 726.6060 Fa: r am r9nl1ac11n0 an TnWA (.Aminal AL, ... h.. l M..� -. (Fax)31933e2,No.9947 P., 1/l/002 UCl Account Number: ..,99¢7-F (irapyneabte> Fromt Xeliow Cab of Iowa City P.O.19oz 42B Iowa City, IA. 62244 (319)338-9777 'Phonot Fax, (319) 339-7302 LestNamo msndwo As of I - � ` 19 a search of the provided namo and date of birth revealed: XNo Iowa Criminal HWoty, Record found with DCT Iowa Criminal History Record a ahad3 DCI # r• i . DCI -77 (08/25110) Received Time Jan. 3, 2018 2:22PM No.2245 1 " to c (PCI ase only) Fin WO me (madno Middle Name revommenaee) ' Koedam Jer m Jonas Date of Hitch (mmdwa Gender__ mmdwe Social Becurl Number rcemmaended C]Male ❑Female Wa verlr(jarntafian: Without a signed wah+er from the subject 01`1110 request, a demplete erlminsl history record may not be releasable, per Code of Iowa, Chapter 692.2, For complete criminal history record information, as allowed by low, always obialg 4 VA1Yel Nature from the sub a re uetf. WalyerReleaseahcro YIvopcMulloetotInvaligionM.Anyulalftly4a n,IoonehsllemslnWnedeylheD maybe fewed ellowedbylsw, WalverS19nafnre: As of I - � ` 19 a search of the provided namo and date of birth revealed: XNo Iowa Criminal HWoty, Record found with DCT Iowa Criminal History Record a ahad3 DCI # r• i . DCI -77 (08/25110) Received Time Jan. 3, 2018 2:22PM No.2245 1 " to c (PCI ase only)