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CITY IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAX
1. Name
2. Mailing Address qi iro 6 �wv,
Authorization Number /a — Iq
(Office Use Only)
APPLICATI .,, OR PEDICAB DRIVER
(Police Departmelrevrawmumt-be malt-
between 8 a.m. to 3 p.m., Monday — Friday.)
3. Telephone: Home (_741L) -36-35
4. Prior experience in transportation of passengers: no rt
Other:
Last
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /
Tyne of offense Where When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?�/ 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? A D
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? /1 tl
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)
nJ
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)
d.d .,dnWadg 09/2010
544AUS -;Pxi
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Drivers license number
understand that if I falsely answer any questions in this application, that this
application may be deniedLknderstand 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 nd all records and documents relating to this application, and I further agree that, if a license
is granted, to comply aj.a�l timelwith 911 of ft provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature of
STATE OF IOWA )
COUNTY OF JOHNSON )
Date /� ��� D
Subscribed and sworn to before me by j0'y'T.rvan2 4? !4 On this day of
SONDRAE FORT.gL �av�
°� Commission Number 158791
My r.nmmieainn FmNaw Notary Public in and for the State of Iowa
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I 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).
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Signalure of PoliceChie esignee
A/ . 7�
Sign ture of City Clerk or designee
Date
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.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
d�ddwadyepedicaba(p2010.d 09/2010
Apr.10. 2012, 4:16PN Div of Criminal Investigation
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,,�''� Iowa Department of Transportation
f�llri� s Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Manes, IA 5D3DM2G4 515-244-9124
FAK:515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
4/6/2012
DL/ID #:
544AG5789 CIA)
Customer #:
5867801
Name:
Goergen, Jonathan Joseph
Class:
C
ID Status:
None
Address:
426 BROWN ST UNIT 6
Audit #:
5445789
DL Status:
VAL
Issue Date:
08/16/2011
CDL Status:
None
City/State:
IOWA CITY, IA 522455858
Expiration Date:
09/27/2016
CDL Cert Status:
None
Endorsements:
NONE
CDL Med Status:
None
Mailing Address:
426 BROWN ST UNIT 6
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
9/27/1982
Supplement:
Mailing City/State: IOWA CITY, IA 522455858
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Goergen, Jonathan Joseph DL/ID: 544AG5789
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
4/6/2012
IOWA Ny°%
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• •S`=s
Office of Driver Services -
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Iowa Department of Transportation
Name: Goergen, Jonathan Joseph DL/ID: 544AG5789
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