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Home My WebLink About13-280 r Authorization Number /_ � F5() i _ 1 (Office Use Only) Ali .:IIIA II ..7100470.so II 1 CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX i First iddle ast 1. Name 6 eSce /14 t r ct 1'l 2. Mailing Address 7 1 9 M ,1oe't -.1-; / i-- 3 A Ci+Al 51-1-la 3. Telephone: Home ✓ 1 I gg..0I Other: 4. P for experience in transportation of passengers: T7('1 V 1 el to iw�if r"t {r v viA 0 ff ,i,i'uv Cl Por Co* CAActr+ s c.S oL i1,�-�--_ 77 r,'✓ to 4F tt c� Pc rw& U k Po r ktsi nesS w&eo- lis. �c-:V ) to �e - n,Ot otwel't� 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere'i~',`. :;�A'`'�''•'I' Type of offense Where When . 1 "5''t 01,47-- Ansor. Co(ANA./ oa/02000 6. Have youbeen 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 6V1I i'o 01911.1.„7 .c -5-(-14` it t 18,114,11,571A-a ,-go -Ott C a-t t to Ob y R- t;. i r.A I 1;;INne2rh. Ce- 6-15-(P- 8. Has your driver's license or chauffeur's 1(cense been suspended or revoked in the last five years? Nib 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) '$0 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) dedknax dn„badg 03/2013 I hereby crti that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number N l y 'C' -7 . I understand that if I falsely answer any questions in this application, tha.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) r,/,1 Signature of Applicant ha / I � �"��/r Date � . / ?._ ( i STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by S`_i-e A }-1-ei n 'tny . . On this / z (4 day of $A\M A ct1 J ' ,J _ Ct.. / WENDY S.MAYER otary Public i i .nd for the State of ..wa •: ,mmiOs'er NHror 28 My Comml sion Expires ow l -t —1 l D ************************************************************************************************************************************************ 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). Signa re of ' /- Chief or designee Date 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. Vit - 7C/1- U / --1 e -13 Signa of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width)and 5 1/2" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update clerWtaxidrivbadgeapp2010.doc 03/2013 Dec. 11. 2013 1 : 22PM Div of Criminal Investigation No. 7883 P. 2/4 •••• L, /lip) F. L STATE OF KOWA ��Opscg. �(aPeyi ap'It'-,, ro ��1" Criminal History :ecorc Cheek `z � I��, �� Request Form � '� �� - `pI 3: w;a . ,tar DCIAccountNumber; 9Dla (irepplienble To: Iowa Division of Criminal Investigation From; CITY OF IO'tA CITY Support Operations Bureau,1"Floor CITY CLERK'S OFFICE 215 E,714 Sheet 410 E WASHINGTON STREET Des Moines,Town 50319 (515)725.6066 IrwTA-rITY 101 14-52240 • (515)725-6050 Fax Phone: 319-3565041 Fax; 319-356-5497 I am requesting an Iowa Criminal History Record Check on: 'Last Name (mendatorol+ Pint Name(mandatory) Middle Name(recommended) qd arson hiss, A� AVv► • Date(J'Birth(mandatory) _ Gender(mandatory) Social Security Number(recommended) l -' I ' t°1100 Male D.Female " 0., r. 761- g 81,E Waiver Information:Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa, Chapter 692.2. For'complete criminal history record information,as allowed bylaw,always obtain a waiver signature from the subject of the request. Waiver Release:Ihereby give permission for the above reg11ssiing ofadlo(to conduce an Town cihninai history record dock with the Division of Criminal Tnvcalgedon(DCI). Any criminal/May dam concerning Met is mal ai cd v, theDCImty bo released as allowed bylaw. Waiver Signature: !Y // / %/ in eQV.{, p'�V]�a / Iowa Criminal Hi tory Record Check Results .. (Darn only) . As of 1 a' ‘l 1 kj , a search of the provided name and date of birth revealed; El No Iowa Criminal History Record found with DCI ( Iowa Criminal History Record attached,DCI# 1014 3 S'S— • DCI initials AT - Received LrnenDec.,_6._02013 1 : 12PM No. 7510 '6 Iowa Department of Transportation Offce of Driver Services (TS!Free)800-532-1121 PO Box 9204,Des:dries,IA 5(1306 9204 515-244-9124 4111110 FAX:515-239-1837 Certified Abstract of Driving Record Inquiry Date: 12/6/2013 DL/ID #: 739NN3017 (IA) Customer#: 1157644 Name: Helgerson,Jesse Adam Class: C ID Status: None Address: 719 MICHAEL ST APT 3 Audit#: 7266746 DL Status: VAL Issue Date: 08/21/2013 CDL Status: None City/State: IOWA CITY, IA 522465539 Expiration Date: 12/20/2016 CDL Cert Status: None Endorsements: L CDL Med Status: None Mailing Address: 719 MICHAEL ST APT 3 Restrictions: NONE Restriction None Date of Birth: 12/20/1978 Supplement: Mailing City/State: IOWA CITY, IA 522465539 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 06/25/2009 06/30/2009 M14 Fall to Obey Traffic Sign/Signal _ _ _ _ Johnson iIA 05/17/2012 06/15/2012 1M14__ 'Fail to Obey Traffic Sign/Signal _ Johnson IA 05/20/2012 06/20/2012D72 Fall to Have Vehicle Under Control 'Johnson !IA 07/20/2012 08/22/2012 F04 'Seat Belt Violation ;Johnson IA Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 11/28/2012 J715045 IIA Name: Helgerson,Jesse Adam DL/ID: 739NN3017 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: .yqp e lanai"-.A.... .A iii 12/6/2013 ç;jCIYa�fniiniiof Driver Office Services' Iowa Department of Transportation Name: Helgerson,Jesse Adam DL/ID: 739NN3017 Dec. 11. 2013 1 : 22PM Div of Criminal Investigation No. 7883 P. 3/4 i " IOWA CRIMINAL HISTORY DCY 00614385 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED- 2013/12/11 DCI:00614385 NAME: HELGERSON,JESSE ADAM DOB SEX RAC HGT WGT EYE HAIR SRN POE 19781220 M W 511 156 BLU BLN PAR IA ADDITIONAL IDENTIFIERS CCH RECORD '*" Ol ARRESTED 20000209 AGENCY: IA0520200 IOWA CITY Pb CHARGE NO- 01 IA STATUTE IA321J-2 OWI TRK#: 049117101 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE IA321J-2 OWI CHARGE CLASS; MISDEMEANOR CONVICTION TRX#: 049117101 DRUNX PRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT JAIL 2D 20000614 FINE $500 20000614 COURT COSTS 20000614 CREDIT W/TIME SERVED 20000614 AN ARREST WITHOUT DISPOSYTION 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, YN THE ABS E OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON I ORNATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION