HomeMy WebLinkAbout12-049Authorization Number /a _ 21
1 1 (Office Use Only)
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
41 0 East Washington Street between 8 a.m. to 3 p.m., Monday — Friday.)
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
First Middle La t
1. Name - t P C
2. Mailing Address 3 SC(i V 0,
3. Telephone: Home to /y Other: q
4. Prior experience in t,�ansportation of passengers: C_ t- ✓ ,e i IA C e- 1
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
6. Have you teqn convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?Fj in
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of o ense / Where �y Wh n
1600Pv,
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? PC
Tvoe 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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
cleWtfl d6vbad8 09/2010
I her bl�certify a I hav issued to me by the Iowa Department of Transportation a valid Chauffeurs license -number
l . 5 (t A Eg . I understand that if I falsely answer any questions in this application, that tho
application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will
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 a license
is granted, to comply at all ti eslwith all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature ofApplican Date Z Z ?-Ole
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by 4-r/' n'L I nt., /:/ . On this U day of
SONDRAE FORT Sara,-,,_ �N,�
Commission Number 159797
My Commission Emires Notary Public in and for the State of Iowa
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1 have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
o? -.42 )a
of Poli a hief or designee Date
of City Clerk or
Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
cleddt dnWadgea 2010.4 09/2010
o2/Feb.20. 2012)10:OBAM Div of Criminal Investigation
DCI IoivNo. 4648
0
STATE OF IOWA
Criminal History Record Cheek
R :
equest Form
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Date of Birth Gender (mWww)
SWal Security Number
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WarverlgJorMoon. Wittiest aelpedwaiver flamthesubject oftherequest, atamplepcriminal hYtoryrecordmay not
bt reftemb,s, per Code of Iowa, Chapter 6922. For com Jeta edminat history re4otd Iorormatloo, a lowed by law, mi"ya
obtain a waiver ti tura hma the enb aet of the EWWL
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Waiver Sigltaffwe:
Iowa Criminal History Record Check Results (Da 94 way).,,,
As of -29 — a seamh of the provided name and date of birth revealed: -'
No Iowa Criminal History Record found with DCI ,
��/111❑ Iowa Criminal History Retold attached, DCI N L
DCI Initial
Received Time Feb. 14. 2012 2:17PM No. 9179
ACIowa Department of Transportation
Office of Driver Services (roll Free) BM -532-1121
PO Box 9204, Des Moines, )A 50306-9204 515-244-9124
OFAX: 515-239-1837
Inquiry Date: 2/22/2012
Name: Lubaroff, Helene Marie
Address: 1316 Muscatine Ave
City/State: Iowa City, IA 52240
Mailing Address: 1316 Muscatine Ave
Mailing City/State: Iowa City, IA 52240
Convictions
Certified Abstract of Driving Record
DL/ID #: 636MM7805 (IA)
Class: D
Audit #: 4102117
Issue Date: 02/16/2010
Expiration Date: 02/03/2014
Endorsements: 3
Restrictions: NONE
Date of Birth: 2/3/1966
Sex: F
History Information
Customer #:
1621790
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD Explanation County IUR
06/02/2007 06/25/2007 S92 Speed 52 IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number 7UR
02/08/2008 425308 IA
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
Pursuant to Iowa Code §321.10, I, Kim Snook, 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:
•;�/°4
2/22/2012
IOWA
D. 0. T.,;�S
f O...... S.
DRI
Office of Driver Services
I
Iowa Department of Transportation
Name: Lubaroff, Helene Marie DL/ID: 636MM7805