HomeMy WebLinkAbout18-018i �IIIl•Jtp���
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 3S6-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. /a -17 15
(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
3. Contact Information (REQUIRED) Email: SDIg90IDgPM;( C-a/V-CellPhone: Sig 930; yC7
(All written co mm unicafl�or sent via email)
4a.1
b.'
5.
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
What happened to the charge? (Circle one)
Convictedismissed Deferred Suspended Plead Guilty Other II
Have you been arrested / charged with any traffic offenses in the last five years? ✓ V (7i
Type of offense
What happened to the charge? (Circle one)
Where
When
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?
Type of offense
9. Have you ever applied
Where
When
o be an Iowa City taxi driver using a different name? If yes, please provide
R
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATEIFft i
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C EVIEW rn
You must apply for an individual Department of Criminal Investigation Report (form availaWd oponagquestt ..
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) C:)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cert' that 1 have issued to me by the Iowa Department of Transport valid Driver's license number
X7-7 �3o1fD issued on 7-1 t, expiring on 7 15 . I understand that if I
falsely answer 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 o�Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by -koi;A PQ L •joNano�— on this / day of
r L.r,,, r.. 7o1A
I 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 date of Driver's license 03 -4—M 0�1
97 0z /3-M
Signatu olice 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.
41�"_ "� zv,��IEK -
Sign ture of City Clerk or designee
/-'�-/
Date
H,}f„
N
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Office Use Only oC-)
2>� W
Approved application
DCI report
State certified driving record
Website update
OmM/iA%IDRNMADGEAPPL92014ar ed.DOC 07/2016
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OmM/iA%IDRNMADGEAPPL92014ar ed.DOC 07/2016
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wwwrJowadotgov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Inquiry
Date:
Customer
Name:
Address:
2/8/2018
4508852
Page 1 of 2
Office of Driver Services
PO Box 92041 Des Moines, IA 50308-92D4
Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
DL/ID #: 075BB3076 (IA) CDL Permit Class: None
Class: C
Schaapveld, Rachel Audit #:
Louise
1813 LOWER OLD Issue Date:
HIGHWAY 6 RD NW TRLR
2531958
02/08/2018
Mailing OXFORD, IA 523229258
City/State:
Date of 12/20/1990
Birth:
Sex: F
History Information
Sanctions
CDL Permit Issue None
Date:
CDL Permit
97
Expiration
12/20/2020
CDL Permit
None
Date:
City/State:
OXFORD, IA 523229258
Endorsements:
NONE
Mailing
1813 LOWER OLD
Restrictions:
NONE
Address:
HIGHWAY 6 RD NW TRLR
97
Restriction
None
Supplement:
Mailing OXFORD, IA 523229258
City/State:
Date of 12/20/1990
Birth:
Sex: F
History Information
Sanctions
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
VAL
DL Status:
VAL
CDL Status: None
CDL Permit ELG
Status:
CDL Cert Status: None
CDL Med Status: None
Type Effective End ACD Explanation JUR Occurrence JUR
Suspended 03/15/2016 05/22/2016 D51 Non -Payment of Child Support IA IA
Name: Schaapveld, Rachel Louise DL/ID: 075883076 (IA)
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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.
N
O
In witness whereof, I have caused my signature and the seal of the Department to be set upon thi9�pcumelPmat Ankeny, Iowa
this date: 4n "*f
D� W _
—it7 W
?V�� rTI
2/8/2018 : Q
e?IOWA :e o
Office of Driver Services
Iowa Department of Transportation
2/8/2018
02/Feb.w 9. 2018,i,qo Cab �
3:22PM Dv ofuwo Cr.i.y ((FAX)3193382',i minal Investigation No. 3423 P.r.1/1
uu, .0 ,e,iun uiuuu uus/002
STATE OF �OWA
Criminal History Record Check,
' Request Form
DCI Account Number: 9967-F
— (If oppl(able)
Tot Lowe DMilon of Criminal Investigation
Support Operations Bureau, In Floor
715 E, V4 Street -
Des Molttes;7owet 50319
(515) 775.6066
(513) 725.60K Pax
Froml _ Xello►v Cab of Iowa City
P.O, Box 428
Iowa City, IA. 52244
(319)330.9777
Yhonet
Fax: —e319)�9-7302
❑Me1e ieItemale 35� gy 53
Walver.mformafionr Without a signed waiver from the sub)oot of the roquaet, a aomplete orlminal history record may no
be releasable, per Code of Iowa, Chapter 692,7, For complete eriminal historyrecorr) Information, aq allowed by iqw, always
Willyer Release: I hereby alvo petmbslon far the &boyo toQuutin 0111410119 4endu4t &n Iowa Odminalbbioryreoord obeck with the Divldon ofCrlminsl
Inrad6etlan MCT) My atm(nd binary data eoneemin` uta�m uln th4 i may be rel W of allowol by I&w,
Waiver Signafurm; L/9y//�%f- A_ D� ,
(DCI use only)
As ofi � 115 a search of the provided name and date of birth
revealed:
No Iowa Criminal History Record found with DCI
`":
1• ,t
Q
Iowa Criminal History Record attached, DCI #
DCl initials
DCI -77 (08/25/10)
Received Time Feb. 8. 2018 12:OOPM No -3776