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Home My WebLink About18-012^+ tllrl®r�11 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. )F3I-0 /oZ (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 "repuired" information will result in denial of the application First 3. Contact Information (REQUIRED) Email: k)rNeC-%Ac %les 4tikqo8ell (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) ZQZ a / b. Taxicab Business Name (REQUIRED) t 11 oLJ C-0 5. Prior experience in transportation of passengers: Last ,4 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? r) 0 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 Where When What happened to the charge? (Circle one) q"3 If- Convicted Dismissed Deferred Suspended Plead Gui Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? (r)t7 Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pr i the��ame(sn DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAI DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE m You must apply for an individual Department of Criminal Investigation Report (form available up@r request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 9y APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certly that I have issued to me by the Iowa Department of Transpo ati n a alid Driver's license number 35 { issued on I d expiring on 1�. 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date - �o- STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by --7"LLl i Q A-, )Zoµ-te "gyp on this zt_v 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). Expiration date of er's nse /0ZZ 61112 G Sig re of Police Chief or designee I I 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. Sig ature of City Clerl) r designee Approved application DCI report State certified driving record Website update Date 0 �—, Z rn 1 Office Use Only �n m �m �;9 w C-.) N aerkRA>OMN94DCEAPPU2014affwlW ooC 0712016 01/1Jan.24. 20.165 8:26AM_eb Div -of Criminal Investigation (FAX)3/933827 o. 3254 STATE OF IOWA Criminal History Record Check: Request Vorm To: Iowa Division or Criminal Investigation Support Operations Bureau, l" Floor 215 E. 7i4 Street 1 Das Molnos;'Iowa 50319 (SIS)725-6066 1 (51S) 72S•6080,Fox K-1/4002 DCX Aoeount Number: _9967-F (IropPlicsblc) From: Xe)lo%, Cab of Xowa CltE P.O. Box 428 Xowa City, U. 52244 (319)338-9777 Phone: Fax: (319'339-7302 1 em roquubmiti un awwa 1 1 111111/4/ --way•�••••••••� Last Nama (nlendeto ) .•••..•. •�••• X'irst Name mandetb ' - Middle Notme N;mme•ndcd) �t7r ink �k1t f)y) n Data of Birth mandate Gender mendela -social-securityNumber reaommmde I DI a l � g� MMale ornale 343 .--4L4 3--40 Waiver 14formationt Without it signed waiver from the subject of the rogNest,a complgta grlminnl history record may no For hlstoryrecorp Information, as allowed by low, always be ralbatable, per Code of Iowa, Chapter 692.2, complete orlmlpal obtain a waiver signature frotn the sub ect of the request Waiver ft etease:1 heraby give pttmisslon fet the above taquadnilaridlol to tonduu sn lows odminal hl.lory reacrd cheak with the Division ofCrlmind . My odminal history del■ concemina me thn b malnteined by thb Dal may be relaued u allowed by law, Invatlpdon (DCO, Waster Signature Iowa Criminal History Record Check Results 2;1 tDel Me Daly) As of I ' `l -19' a searoh of the provided name and date of blrt�-{evea]'9dr jt v;'•-' No Iowa Criminal History Record found with DCI "V, rn rn Iowa Criminal History Record attached, DCI i! I o= w O DCI initials ns DCI -77 (0812S11 0) Received Time Jan.23. 2018 2:17PM No.3221 CIowaDepartment of Transportation ofte of Omer Services (Toll Flee) WO -532.1121 PO Box 9204, Des Manes, LA 50306- 9204 515-244-9124 AO FAX: 5115-239-1837 Certified Abstract of Driving Record Inquiry Date: 1/22/2018 DL/ID #: Name: Romine, Julie Ann Class: Address: 285 HAYWOOD DR Audit #: 12/09/2017 CDL Status: Issue Date: City/State: IOWA CITY, IA Expiration Date: 522451525 Interstate NONE CDL Med Status: Endorsements: Mailing Address: 285 HAYWOOD DR Restrictions: Permit, Corrective Supplement: Date of Birth: Mallinp IOWA CITY, IA Sex: City/state: 522451525 Medical Examiner Type CDL Medical Examiner's Certificate 235ADS385 (IA) Customer #: 4322794 C ID Status: None 2378893 DL Status: VAL 12/09/2017 CDL Status: VAL 10/21/2018 CDL Cert Status: Non -Excepted Medical Examiner License Number Interstate NONE CDL Med Status: Certified Commercial Learner Restriction None Permit, Corrective Supplement: Lenses Medical Examiner Phone 319 339-3921 10/21/1984 Medical Examiner Type F Certificate Specifics Explanations --"r C-)� Medical Examiner First Name Ernest _C �a _ Medical Examiner Middle Name Manuel IL 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 11/01/2017 Medical Certificate Expiration Date 11/01/2019 c Date Added to CDLIS Driving Record 12/09/2017 History Information Convictions cJ �n Citation Date Conviction Date ACD Ez lanatbn a --"r C-)� County m _C �a _ County 7UR 04/20/2016 05/16/2016 M85 Telling While Drivin IL Name: Romine, Julie Ann DL/ID: 235AD5385 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 time 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: 1/22/2018 Office of Driver Services Iowa Department of Transporatlon Name: Romine, Julie Ann DL/ID: 235AD5385 N Q CYN C� iwrf � ' W y O N