HomeMy WebLinkAbout18-021CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319)356-5040
(319)356-5497 FAX
IDENTIFICATION NO. S, nZ1
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
First
1. Name (REQUIRED) - r -,v
Last
'r
2. Address (REQUIRED) 93--) 1 U C k r i r C k 1-;) r'�l -P
3. Contact Information (REQUIRED) Email: Shy. • pfricrgenO lmai I Cell Phone: 71 8� q 334
(All written c6m�munication sent via email)
4a. Driver's License expiration date (REQUIRED) 3- 17 _ ,� 01S
b. Taxicab Business Name (REQUIRED) y -e) i/1 W r A
5. Prior experience in transportation of passengers: 11 by)
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Typeofoffense Where When
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? V ?IS
C )`l l
Where
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pJFOviAe ttVLPr
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De) -5
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATe£ERTI4101
Q
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHO RESAEW
You must apply for an individual Department of Criminal Investigation Report (form available upon -request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I heret r nave issued to me by the Iowa D artment of Transportation valid Driver's license number
$(9 F %%�, _ issued on ,� - �8 expiring on -/ ) I understand that if I
falsely A nswer any questions in this application, that this application may 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 authorization to be a taxicab driver 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 �_; Date aO i
lIHHfMflHY4HY4H#fHlHllfHfHlH4H}}!f f 441##ff H#N11ff YYfH####1lff##1iffHlHHHIH}###HY#Ir}}#fH#lHlfff4HfH##f###fa#1HMflHIH
STATE OF IOWA )
COUNTY OF JOHNSON )
u�bscribed and sworn to before me by Trp t) 5 C. on this Z -c7 day of
� i V*NDY S. MAYER
Commi 4 Number 729428
.jiiExp ree Notary Public in apctfor the State of &we
HH1nWkf1(flftfYYtk4Hfffff4fffiffHfliHefHftYiYftfffffl(f}R!I(1�fffef1fflfftYfftaffif#Y�kffiHffifffffflfftkHH1HHHRIrf4
have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration dar' icense
�f7
ign a of Police Chief or designee Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
-,:;ac —/ 2
Sign ture of City Clerk or Obsignee Date
HHrf f f YYYHfIffHfHHarmaHH#HraarHHHrfrHHHHYfaaaaaaaraaaaarlrrHlHH:ff Yff f YHHYaaaaYf eaaa4aa}raffiffHYaf�f�,aYf YYe#aaHHHfff
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Office Use Only D n rT*t
�-� o r
Approved application ..4 rn
DCI report
State certified driving record
Website update tv
a&wr�MNSADGEAPrLe201� Doc 07/2076
Feb.19, 2018 8:38AM Div of Criminal Investigation No.4125
021M"18 13:25 YONOW Cab TAX)319 338 2708
STATE (1
F XOWA
CriminalHistory Record
Request Form
To: Iowa Division of Criminal investigation
Support Operations Bureau, 1" Fleor
215 E. 7b Street '
Des Moines;'Iows 50319
(515) 72$6066 •
(515) 725-6080� Fax
T am requesting an Iowa Criminal History Record Check on:
P. 2/3
P.002/002
DCI Account Number: 9967-F
(If applloablo)
From: Yellow Cab of Iowa City
P.O. Box 428
Iowa City, IA. 52244
(319) 338-9777
phone:
Faz: (319I339-7302
Last Name (menCalory)
First Name mender
Middle Name (r000mmended)
P-eA.e,-s,n,
) v Cb' ,
e j a tr 1 C
Date of Birth (mandatory)
Gender (mendato
Sosial-Security Number- (r%c*mmenda
❑Female
�1 I CppZ
waiver InjOrrll(WOM Without a signed waiver from the subject of the request, a complgte grlminal history record may no
be releasable, par Code of lova, Chapter 692.3. For comoiet_e criminal history record Information, at allowed by law, always
obtain a walver signature frofn the subject of the request
Waiver Aclease: i hacby give patmisatop fortho above rcyuosUna offioiel to conduct an Iowa criminal hietoryrecord check with the Division ofCrlrWnel
Investigation (DQ. Any criminal history date eonoemlng me thN Is malnlalnra by tho DCi may be released u ellowca by law.
Waiver Signature:
Iowa CriminalHistory Record Check Results (DCT bm only)
As of"��- �X a search of the provided name and date of birth revealed
� P1
❑ No Iowa Criminal History Record foupil with ACICA
'1
Iowa Criminal History Recotd attached, DCI # qas
1)CI initials =t >�
n.._•...I T:_, nrT_��(OQiI',alm,.,0ott u. nani
Feb.19. 2018 8:39AM Div of Criminal Investigation
IOWA CRIMINAL HISTORY DCI 00951853
MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1
DATE PRINTED-
DCI:00951853 2018/02/19
NAME: PEDERSON,TRAV
PEDERSOH,TRAVIS CLARK
DOB SEX RAC HGT WGT EYE HAIR SKN POB
19910308 M W 511 176 HAZ BRO FAR IA
ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y
TAT L ARM
TAT R ARM
CCH RECORD ***
01 ARRESTED/TAKEN INTO CUSTODY 20120305
AGENCY: IA0180100 CHEROKEE PD
CHARGE NO- 01 IA STATUTE IA708.2(2)
ASSAULT CAUSING BODILY INJURY -1970
TRK#: 089158201
COURT DISPOSITION
AGENCY: IA018015J CHEROKEE CO DIST COURT
COUNT NO- 01 IA STATUTE: IA708.2(6)
ASSAULT
COURT CASE ID: 03181 SRCR024388
CHARGE CLASS: MISDEMEANOR CONVICTION
TRK#: 089158201
RESTITUTION
SENTENCE DISP EFF DAT
FINE $65 20121012
02 ARRESTED/TAKEN INTO CUSTODY 20121223
AGENCY: IA0710000 OBRIEN CO SO
CHARGE NO- 01 IA STATUTE IA123.46
CONSUMPTION / INTOXICATION - 1978
TRK#: KLOO17901
COURT DISPOSITION
AGENCY: IA071015J OBRIEN CO DIST COURT
COUNT NO- 01 IA STATUTE: IA123.46
CONSUMPTION / INTOXICATZON - 1978
COURT CASE ID: 03711 SMSM024137
CHARGE CLASS: MISDEMEANOR CONVICTION
TRK#: KLOO17901
SENTENCE DISP EPP DAT
No. 4125
FINE $65 20121224 CD
n
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD TA
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF n
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 �:X
BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD :Y
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION
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P. 3/3
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ARTS
Page 1 of 2
C,J10WA00T
SMARTER I SIMPLER I CUSTOMER DRIVEN W1NW'IOw7CiDtgOV
Office of Driver Services
PO. Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244.9124 18DG-532-1121 I Fax: 815-239-1837
www.lowadoLgov
Inquiry
Date:
Customer
#:
Name:
Address
2/15/2018
5780588
Certified Abstract of Driving Record
DL/ID #: 486AF7752 (IA) CDL Permit Class: None
Class: D
Pederson, Travis Clark Audit #: 2552799
932 DUCK CREEK DR Issue Date: 02/15/2018
City/State: IOWA CITY, IA
522468674
Mailing 932 DUCK CREEK DR
Address:
Mailing IOWA CITY, IA
City/State: 522468674
Date of 3/8/1991
Birth:
Sex: M
Convictions
Expiration 03/08/2024
Date:
Endorsements: Chauffeur 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrictions:
IPF
ID Status:
VAL
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
L8 102/04/2018 AD51
Status:
IPF
CDL Cert Status:
None
CDL Med Status:
None
History Information
Citation Date Conviction Date ACD Explanation IUR County
D2/17/2013 /08/2013 '.592—15peed
;03IA Cherokee
Sanctions
End ACD
Explanation
7UR Occurrence 7UR'
L3 _ 10 27 2015 D51
�--4--
Non Pa Tent of Child Su rt
1_ Y ems.
IA !IA
- --
_ ->—
V 08/13/2017D51
.
INon Payment of Child Support
TA II
L8 102/04/2018 AD51
^Non -Payment of Child Support
IPF
Name: Pederson, Travis Clark DL/ID: 486AF7752 (IA) o f�
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa OepaitmentWTranS ortation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that thiC a'Qrue and ac ra copy of
an official record currently In the custody of said office, and that I have been authorized by the DlrecCwP5f thMwa 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:
wivmiR
HfC 10
:,,•••••••;,pith,
2/15/2018
IOWA
D0. T.;�£
. :K-,
rf �R�� 4E�
Office of Driver Services
`11.x,..----
Iowa Department of Transportation
Name: Pederson, Travis Clark DL/ID: 486AF7752 (TAl
Page 2 of 2
2/15/2018