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Home My WebLink About12-250CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX —T_ First 1. Name ( _VW (W, 2. Mailing Address 3. Telephone: Hor Authorization Number 1a- -ISD (Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday – Friday.) Ir, _3 0Z) o7 Other: 4. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? b `'� Type of offnennse Where When I–u-� 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 7. Have you been convicted of any traffic offenses in the last five years? , Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?� 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) cierkkmidnwadg 09/2012 I hereby yy certify that ave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number Z--/ %22:s-(""(" 4-I h . I understand that if I falsely answer any questions in this application, that this application may be denied. I understand that if I falselX answer any of the questions in this application, that this application will be denied. I agree that in making this application, I' onsent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records anocuments relating to this application, and I further agree that, if a license is granted, to comply at all times with all of the pr 'ons of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) /J, / d Signature of Applicant`�� i� Date l STATE OF IOWA ) COUNTY OF JOHNSON ) /S%�scr ed and sworn to before me by On this day of KELLIE My 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). 2kWf Signature of Police r of or/designee YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. ign re of City Clerk or designee Taxi cab businesses are required to provide Driver Identification cards. Office Use Only Approved application DCI report State certified driving record Website update ao -/9- /„- Date derkb)dddvbadgeaW2010.do 09/2012 Your name Address y cayo f2 5 Ci /State/ i Phone# 3 r4- TA, -5 0 State of Iowa Division of Criminal Investigation 215E7'"St Des Moines IA 50319 Ph. 515-725-6066 Fax 515-725-6080 Iowa Criminal History Record Check Walls -In Request ReouestinQ an Iowa criminal history record check on: Fill in all shaded areas. Last Name A'pelIlliido (mandatory) FirstName Primer Nombre (mandatory) Middle Name Segundo Nombre (recommended) Date of Birth Fecha Nacimiento (mandatory) Gender Genero (mandatory) Social Security Number (recommended) V c ❑Male dnYernale &� p-70 � - 33IC6 (/ Waiver .Sl nature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.) Results As of \6\\ M `Z a name and date of birth check revealed: ❑No record found kP ecord attached, DCI # Dr DCI initials Receipt Number of requests' x $15.00 per last name = Total amount $ nCIOSEONLY Method of payment: ❑cash ❑money order ❑check # MYMasterCard or Visa Cardholder's name I CZ Last 4 digits of MC or Visa % DCI Credit Card Number # Exp. Date CO fV Method of payment: ❑cash ❑money order ❑check # MYMasterCard or Visa Cardholder's name I CZ Last 4 digits of MC or Visa % DCI Credit Card Number # Exp. Date IOWA CRIMINAL HISTORY DCI 00596948 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED - 2012/10/18 DCI:00596948 NAME: SHROCK,TERESA GRACE DOB SEX RAC HGT WGT EYE HAIR SKN POB 19821102 F W 506 112 GRN BLN LGT IA ADDITIONAL IDENTIFIERS PRCD L EAR PRCD R EAR SC L KNEE TAT BACK 01 ARRESTED 20040406 AGENCY: IA0520200 CHARGE NO- 01 OWI TRK#: 101134901 CCH RECORD *** IOWA CITY PD IA STATUTE IA321J.2 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE IA321J.2(A) OPER VEH WH INT (OWI) / 1ST OFFENSE COURT CASE ID: 06521 OWCR068352 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 101134901 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT JAIL 2D 20040630 FINE $1000 20040630 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION N Iowa Department of Transportation Office of Driver Services (rdl Free) BDO-532-1121 PO Bax 9294, Des Milnes, IA 503Dfr9204 515-249-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 10/19/2012 DL/ID #: 139TT5642 (IA) Customer #: 4565304 Name: Shrock, Teresa Grace Class: D ID Status: EXP Address: 4487 490TH ST SE Audit #: 5256698 DL Status: VAL 06/06/2012 _,08/24/2009__.._ _592 3.06/13/2012 Issue Date: 05/27/2011 CDL Status: None City/State: IOWA CITY, IA Expiration 11/02/2013 CDL Cert None 522408288 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 4487 490TH ST SE Restrictions: NONE Restriction None Date of Birth: 11/2/1982 Supplement: Mailing City/State: IOWA CITY, IA Sex: F 522408288 History Information Convictions Citation Date Conviction Date, ACD Explanation _ County JUR 04/05/2004 A201. Operating While Intoxicated 152 IA 07/13/2009,.......,,_,_,. 406/30/2004 �.. IA ,IA Speed 52._ SIA 06/06/2012 _,08/24/2009__.._ _592 3.06/13/2012 !.S92 .. _ ;Speed .52 IIA Operating While Intoxicated Test Refusal/Test Failure Violations Occurrence _ACDE_xplanation JUR __ 04/05/2004 Al2 OWI Test Refusal €IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 01/15/2009 488786 Sanctions Type Effective End ACO Explanation Occurrence JUR JUR Revoked 104/16/2004 04/20/2004 �Al2 OWI Test Refusal ........ TAIA ._ _... ... . Revoked ,. 06/16/2004 ... ;06/12/2005 .L... €Al2 ......._ ;OWI Test Refusal �.. IA ,IA Name: Shrock, Teresa Grace DL/ID: 139TT5642 Pursu6nt toIowa Code 4321.10, 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 10/19/2012 IOWA '''' =4-6 0. T. waztov=tk U9NEA g- Office of Driver Services «�� Iowa Department of Transportation Name: Shrock, Teresa Grace DL/ID: 13MS642 Form 431009 Iowa Department of Transportation Office of Driver Services PO Box 9204, Des Moines, IA 50306-9204 Teresa Grace Shrock 4487 490TH ST SE IOWA CITY, IA 522408288 Cust No: 4565304 DL No: 139TT5642 Date: 10-19-2012 (Toll Free) 800-532-1121 515-244-9124 FAX: 515-239-1837 Sanction No: 2547450 The withdrawal of your Iowa motor vehicle privileges due to Non -Payment of Iowa Fine has been rescinded and removed from your Iowa driving record. You are eligible to operate motor vehicles in Iowa. Your license is valid, unless expired. If your privilege to operate motor vehicles has been withdrawn In another jurisdiction, you may be required to provide clearance information from that jurisdiction. LWVA FA AigirdpJ �° Director, Office of Driver Services Oct, 22' 20122 9:17AM6 Div of Criminal Investigations No. 06114 P. 1/2 K;- MJARM��: STATM OF IOWA 1C9r11nrlaraal.ffig$arr^yReco>rd Cheek Request Form To; IMA -blvlaloriof CriminalYhyastfgaffm support Operations $uroar(, 5'rSolaar 2157, 7i°Sfroet Desivtolnas,Iolva 50319 (9" 72g•doed (515) 725-6000 va)t Last KU? ? L 4 wayeFXt(J0) bo rdlealable, ) AM% a waive: �2i)iEN.iZe�ep YrIV0 f9arron (DOD. Won" withoat a Coda bZXalya, Cb Waiver )?CTAcoountNUtn6er7 ` DUD ' � �fxpplireblc) Prow 0j= ov IOWA CITE OXTXX CLEm's O mir-E 41 (1 r WA s7iTPT R SlUpFr' Phoaei 919-356--504.1 haxl 91a_�55--5497 _�.' 7sr'ory Record Cheok on: her Owe aw) -r *6M IhMbleet of th o YegnaA(j a corohlafo ol'frOnAl hlsfor'y r€eord 1)lay llot Var o a'orlminalhistoryrecordtnforinntlon,nvallowodbylo�,AJWAys alfeg OMIAr (o wilduof an Yowa odm(nal6isLoryreaord ohecY,wYh IhaDAM410n gfCriminer Mafnmlocd ey the pplmay60 rolmod as elfowcd byfnw, I i y.V tY (i Vllllllll4A xr/a�uV; {/ ,a.4G6iVA 11 u_.LLb VA�J(S,tliJ UAL.Y , NCI uro only) As of 10- " � a , a seUoh oftlto,grovid-ed name aird data of bflth.sevealed: ; No Towa Crdxnf)fa1.Ffatoty Record folmd witILDCX Iowa Criminal T-l'istpzy,Redotd attached, DCIir S Q (O CI LJ d •'• , .- -'.=' co Dcrfulifals Received Time Oct, 16. 2012 2:56PM No.5337 ".Oct. 22. 2012 9:1]AM Div of Criminal Investigation No. 0614 Y. 2/2 IOWA CRIMINAL HISTORY DCI 00596948 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF i DATE PRINTED- 2012/10/2� DCY;00596948 NAME; SHROCK,TERBBA GRACE DOB SEX RAC HGT WGT EYE HAIR SKN POB 19821102 P W 506 112 GRN BLN LGT YA ADDITIONAL IDENTIFIERS PRCD L EAR PRCD R EAR SC L KNEE TAT BACK CCH RECORD -'* 01 ARR80TED 20040406 AGENCY: IAGS20200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA3210'.2 OWI TRK((: 101134901 COURT DISP091TION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE IA321J.2(A) OPER VEH WH INT (OWI) / IST OFFENSE COURT CASE ID: 06521 OWCRO68352 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 101134901 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT JAIL 2D 20040630 FINE $1000 20040630 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BS INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD CO THE SUBJECT OF YOUR INQUIRY. DI ION OF CRIMINAL INVESTIGATION