HomeMy WebLinkAbout12-104� r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
riMkt =
Authorization Number I Q_ 0 /o
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Last
r, W'nc,✓ G I.1
2. Mailing Address t 360 0m (G-- y , lei 5,2-2'( 0
3. Telephone: Home Other: �3/ . 5-9Y_ a?OT
4. Prior experience in transportation of
p9i
1e
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? AJ Z)
Type 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? &'()
Type of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
t(e-5
When
Type of offense Where When
S pk¢& Jt L t4S w CIS . 3 /5-. v<i'�
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Alb
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) 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)
oiarwtaxianwada
09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number.
la7 %i0$y ivZ . I understand that if I falsely answer any questions in this application, that this
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 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_ 7L/�� Dates • Z (• f Z
STATE OF IOWA )
COUNTY OF JOHNSON ) I/
scribed an swor1 to before me by \ S O.SQ (� LCt S 60'O L i . On this 2 day of
O 1 L.�.
�—'K1L K. TUTTLE
��I mineinn Numbef 221819 Notary Public in and for the State of Iowa
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).
Sigriature of Police Vhief or designee Date
Sig f City Clerk or designee Date
After Police Chief and Ci Jerk 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
clleMJ idnvb d9ea,2010 We - 09/2010
May.17. 2012 3:33PM
Div of Criminal Investigation No.5517 P. 1/1
9969 "N NNE ZIOZ 'hl 'AVN OW11 Pania33y
STATIC OF IOWA
Criminal History Record Check
Request Form
Tol Iowa DWblub or Crlminallnvesrigatlon
Support operations Bureau, la Floor
115E.711slreet. _
Dn rdolass, torus 50319
(515) 72S -6w
(515) 715.60110 Fes
DC1Account Number.'
(lh 1u61e)
From? May(:r5' A)(II
Phol"I 0140 338' �2jIM
0
I am uestin an Iowa Lnml rvosu
Last Name male
Laskowski
A"UlY
FlrotNameGwa.
Jas-P�►
Middle Name cemmeneedi
WaHe�
Hato of 1ljrth (ne gem
Gender . a.n
Social SecurityNumber ttoomma+dee
Z5-. 19'73
�tsate OFemale,
ge Sl
Watvarlit/prmarJon: whboal a signed waivertrom the subject or the request, it complete criminal history record may mof
Chepler 6917. For l omnit$• criminal hbtory record Iotoematbn, as ■dowed by law, etwspr
be velemble, per Code orlows,
ob tsin a wgtormlituiduyetromthesuhectorlber uest.
Jenpnaon an elee�r� �oYbloMnGl1WbenleuWu%UooWbytLwNckwim rite bi�uiau olGLN,x1
f�vm lon�turJ�NV n4Neveinw
Waiver Signature:
Inws, riminal MBtory Record Check Results (DCr waeNy)
As of a search of the provided name and date of birth revealed;
,No Iowa Criminal History Record found with DCI
O lows Criminal History Record attached, DU g :. ••
DCl initials
r" u;
Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Manes iA 503D5 -92G4 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
5/15/2012
DL/ID #:
127AC8472 (IA)
Customer #:
5231945
Name:
Laskowski, Joseph
Class:
D
ID Status:
None
Walter
Address:
836 WALNUT ST
Audit #:
5981226
DL Status:
VAL
Issue Date:
05/15/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
04/25/2017
CDL Cert
None
522403340
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
836 WALNUT ST
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
4/25/1973
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522403340
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
03/15/2008 04/15/2008 w `S92� Speed �•• •-=52-� IA-•
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
10/20/2008 _.._ _ ..467866_..._ ._.. _... ...-_FIA 'r
Name: Laskowski, Joseph Walter DL/ID: 127ACS472
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:
?"""•%G/�4
,y
5/15/2012
IOWA
.
D. 0. T.�
7p'OR..4 S'c =�
office Driver Services
of
Iowa Department of Transportation
IOWA
•
'
USA
IA
LAS SKI
JOSEPH WqLTER
636 WALNUT ST
IOWA OITY,1 52240
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