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Home My WebLink About18-008CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 5 2240-1 82 6 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) . IDENTIFICATION NO. — (Office Use On y) 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 Last 2. Address (REQUIRED) 17'�Q Doe SWI w n 3. Contact Information (REQUIRED) Email: kbOuvt� 14�J�„� 1, ccyt, Cell Phone: 402 102 - 20$1 (All written commun cation sent via email) 4a. b. 5. 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? IV 0 Type 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? k 11 c Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other , 1 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N 0 Type of offense Where When N 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please jr)We tl&name(s) ..-c N — DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CER -MED I DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICEICHIEF RSVIE" You must apply for an individual Department of Criminal Investigation Report (form available ulfbn re"t). u3 (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 epa ment of Transporta'�'o^n'ava'lid Driver's license number 415 ACS g4Il issued on i ?_ I L expiring on ��/. I understand that if I falsely answer any questions in this application, that this app ication 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 ApplicantlL�Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Km. 14- ., on this Z- day of WENDYS.MAYER I— i m,,m 72"28Notary Public 9 and for the State **H*HH**ffHfflHH+*++++++++++++++++**++++++++++++++++++++++++++++++++++++++++++e++++++++++++++++++++++++++++++++++e++m+++++++++++++++++++ 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 Driver's license V �� Signal uy of I' a lief or designee Date I I 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. t�Signature of City Clerk#r designee Date HH*H11f 11!}#HHH}fH*##}fflfNflf f f#fllflfl11111Hffn#f}#ff#f}tiff f f 111!11 1H1ff1ff f 111 f 1fff11HHHlfflf f 1ff 1111 11H1fH}HH1111f11ff 1H aen✓rnwoarvanocEAPPLe2014anWoded.Doc 07/2016 Office Use Only o Approved application. -- DCI report �� w State certified driving record --t r rn Website update o 0 7r %D cn co aen✓rnwoarvanocEAPPLe2014anWoded.Doc 07/2016 0 CIowa Department of Transportation Office of Dmw Se^nces (Toll Free) 800-532.1121 PO Bax 9204, Des Modus, IA 593069204 515.244-9124 AO FAX -515-239-1837 CLEAR DRIVING RECORD Name: Bouma, Kai Harper OL/ID: 495AG5311 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 offlclal 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: `'11 1` 1/15/2018 F 1 IOWA ': D. 0. T.� �f - •...,.. - .� Office of Driver Services n Mmira+� Iowa Department of Transporatlon )> C-) CNS.) Name: Bouma, Kai Harper DL/ID: 495AG5311 [r— a m rri :;0 s ox � T� c n Co Certified Abstract of Driving Record Inquiry Date: 1/15/2018 DL/ID #: 495AG5311 I[A) Customer #: 5792438 Name: Bouma, Kai Harper Clow: C ID Status: None Address: 1280 DOE RUN DR Audit #: 9746761 OL Status: VAL Issue Date: 01/29/2016 CDL Status: None City/State: NORTH LIBERTY, IA Expiration Date: 01/07/2024 CDL Cert Status: None 523179102 Endorsements: NONE CDL Med Status: None Mailing Address: 1280 DOE RUN DR Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 01/07/1988 Mailing NORTH LIBERTY, IA Sex: F City/State: 523179102 History Informatiop CLEAR DRIVING RECORD Name: Bouma, Kai Harper OL/ID: 495AG5311 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 offlclal 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: `'11 1` 1/15/2018 F 1 IOWA ': D. 0. T.� �f - •...,.. - .� Office of Driver Services n Mmira+� Iowa Department of Transporatlon )> C-) CNS.) Name: Bouma, Kai Harper DL/ID: 495AG5311 [r— a m rri :;0 s ox � T� c n Co Vall. I1. LV IV II•IJX1111 VII VI VI 1111 Mal I II V C J I I b a I I V 11 Ol/le/2010 12:38PM FAX 3103307302 STATE OF IOWA 10 Criminal History Record Check Request Form To; Iowa Divlsion of Crlmlual investigation Support Operations Bureau, r" Floor 21S E. 7' Street Dos Moibes, Iowa $0319 (515) 725-6066 (51S) 7254080 Fax I am teauosting an Iowa Crinilml ule!!A . n.,....a nt._ r- nV. VJVJ I/ I to 0002/0002 ryr DCI AcoountNumbter; 9967-F Ufappbcabk) From: Xellowca ofiowp,Ci�.� P.O. Box 428 Iowa City, IA. S2244 (319) 339 9777 Phony Fax: (319)339-7302 ) Last Namo (;(.mdao First Name (mondal Middle Name rmmalllcAdad) �aultit , � (DC) We Date of Birt > Gender (mandato Social Security Numbor neommmd h,. Male ❑Female -23—SIY3 Waiverinformat'ion. Without a 61ened waiver from the subject of the request, o compieto crimlaal history record may not be relcasable, per Coda of Iowa, Chapter 692.2. per eemaletC crlmlaul history record iaformailon, ss allowed by taw, always obtain a waivers) stare from tbo suh eat or the re uest Waiver Release:t hacbyelve p nnialon fit the Weave retusting oMcia) to wnddet an Iowa orbuloal all�my mord chockwi(h rhe Dlrlaioo orCimtnar Invmtllasloo(M). Any crbolaolblaocy data conoemin meth IsmolmaiacdbytheDOmaybe«IeasedAsallowedbylaw, Waiver Signature: ) L— Iowa Criminal History Record Check Results (DC) We only) As of \�l �� a search of the provided )tame and date of birth revealed: h,. No Iowa Criminal hlistory Record found with DCI m' ❑ Iowa Criminal History Record attached, DCI # �-- :_ s DCI iniRals DCI -77 (08/25110) Received Time Jan. 16. 2018 12;34PM No, 2670