HomeMy WebLinkAbout12-139CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-S040
(3 19) 356-5497 FAX
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
/�)_ -/
(Office Use Only)
1� First Middle Last
1. Name t�lt1lV.Ui OxiyP.�e- PR4YVtEk
2. Mailing Address L -k) Z;';— al /
3. Telephone: Home Other: 3(9 - 329 0 4 zcp
4. Prior experience in transportation of passengers: O WC -A R 0 F ltrw A G -T-1 �(
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 1J11011
Type of offense Where When
tiIFt-
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 When
N)IA
7. Have you been convicted of any traffic offenses in the last five years? WS
Type of offense Where When
A #FT 6el-T V To [- P�TZp fy Co - S -1 TFf 3fab I 1 1
Trkpmo_ac Rrrryc'r r C-6, 5-�_--4 (PI qll)—
b. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ti [A
Tvpe 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)
dedcAutdrivbadg 09i2Bi-0
fla°I
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license yumber
L4 s;; \/ 4 .S'7 o ::Z . 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 wit,
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 l Date % oL Lo 7 oZ
*f**N*f11fN1Nf*1f11NH1f1fNfHfff�fHH1H1f1HH*HN##NR##*#1f H1f11#NHNNNHHHfNH1HfnHN1fHR4R*M*N
STATE OF IOWA )
COUNTY OF JOHNSON )
scribed and sworn to before me by
On this ab day of
in and for the State of Iowa
'7\3\"4
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).
vltz e_-� —
Signature of Police Chidesignee w
Sign ure of City Clerk or designee
-2G . j0" r
—' Date
7 ' -zgo -- /c;? -
Date
NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names placed on the city website at
icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
H##*HH#*HN#H###RR*#N#*i*NNtN1Nfi*1NH1f f11f11NN1f f iffiklNfNffkf*iiH.1f*1N#*###NH#if#i##*N*1NN#.Y11HN*f*f 11141!#fflflNff
Office Use Only
Approved application
DCI report
State certified driving record
Website update
de*m dmeaegeapp2010.aoc OWEMB
Q Lao 1Z
Iowa Department of Transportation
Office of Driver Services (Toll Free) 80-532-1121
PO Box 9204, Des PAcOnes; IA 503€36-9204 595-244-9424
r FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
7/24/2012 DL/ID #:
432YY5707(IA)
Name:
Prymek, Donna Marie Class:
D
Address:
2175 KOUNTRY LN SE APT 1 Audit #:
5453760
None
Issue Date:
08/18/2011
City/State:
IOWA CITY, IA 522409302 Expiration Date:
09/23/2015
Endorsements:
3
Mailing Address:
2175 KOUNTRY LN SE APT 1 Restrictions:
Corrective Lenses
Date of Birth:
9/23/1979
Mailing City/State: IOWA CITY, IA 522409302 Sex: F
History Information
Convictions
tion Date Conviction Date ACD Explanation
0/2011 y03/23/2011., F04 Seat Belt Violation
?012 ;06/19/2012 IN82 Improper Backing
Customer #:
3875157
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
County JUR
57 IA
52 TA
...� ;,ts - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
06/04/2012
1688631 IA
Name: Prymek, Donna Marie DL/ID: 432YY5707
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:
......•.. �j'y
7/24/2012
IOWA
D. O. T..:S'-'S-,;'
C4-ry ._,
0"
'R
A.
f •••••'
Office of Driver Services
„ `DflIVEN —
Iowa Department of Transportation
Name: Prymek, Donna Marie DL/ID: 432YY5707
09Jul. 11. 2012
a
4:13Ph1,abc0iv of Criminal Investigation 31"38-2708 No. 3134 Pr 3
STATE OF IOWA
Criminal History Record Check
Request ]Form
DCI Account Number: 9967-F
' � (ifapplieable}
To: Ip\Va Division of Criminal Investigation From: _Yellow Cab of Iowa City
Support Operations Burenu, I" Flopr P.O. Box 428
215 E. 7" Street
Deg Moines, Iowa 50319 Iowa City, IA. 52244
(515) 725.6066
(SIS) 7256080 Fax (319) 338-9777
Phone;
Fax; (319) 339-7302
•_ne_ :,tin an IOWA''rin?inal HIsto Record Chee7c on:
l Tin ,�nM ,
. Sf r.. C mm;'r, �.1• First NRMC (mondaloq•)''� iY(11I�,1C Name (,mommend
60to YYIf'iP
Date of Birth i - Gender(mandw1 o 'SoclalSecuri Number(rcommmdtd)
>; 79 �MA(e Lk]Fetnale. L1�6 bCe"�`i(.(.i� _
'Infonflatioil.Withbutasigtter( waiver fronrthe subJecr.oftheregpesyacdmpletoorirninalhistolyr;aoid•m y -trot
:Mlltile, per Codc of Iowa, Chapter 692.2. Far comp]eele criminal history record lordrmaiion, as allowed by law, al ,ways
.::•::){u a lyaiver Rl nafnre from the sulee, of the rc nett:
I
)T HIYer iie1B(lSf:: [ hereby givo permission for he abaYt requcslin6 omelet to condud an Iowa ttiminalLialofy record chock rrilh the DiYlat0a otCriminal
' rnvnllg,Lfan'(YX:p, Anyrdminel Mnory Oatacoft mingmorhatlrmalaraln yihc DClmay Eerelcot4aeallowedbytew.
— H'aiverSignatnre'_
Iowa
�7Criminal History Record Check Results (DCramCay)
As of �— -/ —/ , a search of the provided name and date of birth revealed:
r
No Iowa Criminal History Record found udth DCT
Jj •
Iowa Criminal History Record attached, DCT #
DCT initials
DCI -77 (06/35!10)
Received Time Jul. 9. 2012 8:01AM No.2252