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Home My WebLink About12-119CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319 35 - 4 (319) 356-5497 FAX Authorization Number 19-1(9 (Office Use Only) APPLICATION FOR PEDICAB DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) Last 1. Name 2. Mailing Address $'2"i lZo05r—%lct.r Si'¢cci 3. Telephone: Home '517. Y 3g- ' -J:feY Other: 4. Prior experience in transportation of passengers: D� clL9 rf D 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 7%O 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?rr c,_ Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? 140 Type of offense Where When 8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? �/ D 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) dedOa dnmad9 09/2010 ' I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Drivers license number =;- 9 G Z Z 12.'4 f . 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::j::::� Date Z 1 I �— +++f++++++++++++++#+++f++++++++++++++++++f+f+++11111++++++++++e++++++#++++##f++f+++f+fff++++++f++++++#++++++++++#f+++#+++++4++f+++++++++++++4+++ STATE OF IOWA ) COUNTY OF JOHNSON ) _ bscuriib de and sworn Itp before me by On this day of L U 4" D K. State of Iowa 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). ef or designee Date 'Z-�Z-/a- or designee 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. 4#4#44;##fY#i#f#######444#;44#;##M##i##i###f4#44#44#f#fYf11114#####i###ff##4#ittf###ff111ff1fff11f#144###f+##1444##ifHf4#-kflffN#####4#1111#11 Office Use Only Approved application DCI report State certified driving record Website update tlerWla dwbadgepe it bappzol O. 09/2010 -Jun.13, 2012 12:06PM Div of Criminal Investigation No.8966 P. 2/2 Jun. D. LU 12 1:ILrl7i uty werK - blty of Iowa (,Ity No. Z459 P. 1 STAU OF IOWA Criminal History Record Check Request Form To, Iowa Division of Criminal Investigation Support Oper•atlotis )lnroau,1"Irloor 215 E, 71h Street DesMoines,Iowa 50319 (515) 725-6066 (515)725-6080 Fax I ala rectuestina an Iowa Criminal Histon, Record Check on: I)CIAccount Number: Jtbaeg ^ P (if applicable) From: CITY OF IOWA CITY CITY CLNRKIS OFFICE 410 N.' WASHINGTONSTREVT IOWA CITY IOWA 52240 Phone: 319-356-5041 Faxi 319-356-5497 Name (mandelory) Mrst Name (mandatory) Middle Name (recommended) iLast FI soeuS �PXIEt.J A 6 r- Eli Date of Birth (mandatory) Gender mandatory SoclAl SecurlLy Number (recommended) //_:� /M8 3 ale ❑Female /'_7 8- 06 — C'" P WoiverIftformallon. Without a signed walvorlrom the subject of the request, a comple(o criminal history record may not be releasable, per Code of Iowa, Chapter 692,2, For complete criminal history record infornraUon) as alimcd by law, always obtain a waiver signature Aomthesubectoftherequest, -Waiver Releiae, I limby eivc pcmilysion flor ilia loconduct anton•acriminaihisioryrccordahe&vilth(ho DlVIsionoferkninal Investigatfon(DCo. Any uitninal hlslary dais hied Wet ism' lamed by thebCI may be released as allowed by taw, 0 Waiver Signature: ffnslr.4e. I ;1s'�6 Iowa � Criminal History Record Check Results . (DCrp%onil) As of �(p�� l/a search of the provided name and date of birth revealed: C t -71 No Iowa Criminal history Record found with ACI ❑ Iowa Criminal History Record attached, DCI # DCI rs(11-71 /nsv')vlpa Received Time 'Jun. 6. 7019 101PM No. 7531 or Iowa Department of Transportation Office of Driver Services (Toll Free) 800332-1121 PO Box 9204, Des Moines, lA 50306-9204 515-244-9124 FAX: 515-239-1837 1*0 Inquiry Date: 6/22/2012 Name: Fischels, Drew Allen Address: 825 ROOSEVELT ST City/State: IOWA CITY, IA 522405648 Mailing Address: 825 ROOSEVELT ST Mailing City/State: IOWA CITY, IA 522405648 Name: Fischels, Drew Allen DL/ID: 796ZZ7271 Certified Abstract of Driving Record DL/ID #: 796ZZ7271(IA) Class: C Audit #: 1909136 Issue Date: 02/27/2008 Expiration Date: 01/31/2013 Endorsements: NONE Restrictions: Corrective Lenses Date of Birth: 1/31/1983 Sex: M History Information CLEAR DRIVING RECORD Customer #: 1093217 ID Status: None DL Status: VAL COL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 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: Name: Fischels, Drew Allen DL/ID: 796ZZ7271 """•tib'/'4 6/22/2012 IOWA.: ). 0. T.w; wav OB�VEO q Office of Driver Services Iowa Department of Transportation