HomeMy WebLinkAbout13-200 Authorization Number I a op
(Office Use Only)
APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
4 1 0 East Waspington Street between 8 a.m.to 3 p.m., Monday-Friday.)
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First , Middle
{-CA. Last
1. Name GIA s 7 I _ �,� �O�e n
2. Mailing Address C7& C)�"Gkh a v"e_) 5), tin
3. Telephone: Home(5) 9' - y�� - 30'4-) Other:
4. Prior experience in transportation of passengers:
-152-1c4 a fic,4 i ► I/) Y1 o �-ro) lam va n vein
-r#ae 5c) m
5. Have you ever been convicted of any misdemeanors and/or felonies in this State o ATr r_�Y- w >,
Type of offense Where 1en'�44/
6. Have yIq�1 e convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense Where When
�� �•��1_ rr .'��^ 'r—=—L Ours¢`" a.�_•�
7. Have you been convicted of any traffic offenses in the last five years? Yes
Type of offense Where When
4-o n 4-{G,-- / _ ..)19 OT /o ) /o<1 10 o / , 'A` !d I
iNo �r14, rne:i n Le 474 r 7----c-4')n 5(S 11 )o /0�1 l c)'-v(31
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? �
Type of offense Where When
9. Ha a 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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
clerkllaxidrivbadg 03/2013
4
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
`_f 3 / X 17 1 .7... . 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 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) ��
Signature of Applicant���'`' �� Date ) I
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ---F.-,x—r, A- 1 Le E. �(‘,A . On this Lc ,1„_ day of
_ N�tary Public ir(and for the State of owa
• % OCMr1MM ' jii
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).
Signature o olice 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.
-( 9— --- 45
Signatur of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/Z" (width) and 51/2"
(height)and prominently displayed to all passengers.
,...******** ..*****************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
•
clerk/taxidrivbadgeapp2010.doc 03/2013
oe„Sep.._6.,, 2013710; 13AM Div of Criminal Investigation -, DCI IoiNo. 6369 P.�I/1
•
STATE OF IOWA
Criminal History Record Check
' Request Form
ear,;�,
DCI Account Number: 1$3..R
�(
� pr.pWwMe)
To: Iowa Division',rerdmtndrn9aagatIon Finn Uv Ar usTAxt
Support Opastime bureau,ri Floor1
ZZSE,7iestreet O E 5T4„cws c;It4
Dm Moines,Iowa 50319 • E0 OK Ai saa9 0
(5rS)733.6o 6
(5is)7Z540oo Far 319) 33I. �H.
• Phone:
. • Fas:. - (3t 9) 551-SP-19
I am mounding an Iowa Criminal Hisroty_Record Check on: -
Iant Name Ormist y Flral Name(m.wmry) Middle Name(recemmendS)
Komar 1A2-A - tiogi.6e
-
Date of Birth(m..a.b y) Gender(m,nd o,ry) Social Seourity Number fmo■mrodoQ
I0 - lar IIRtj OMate 'Female (to ' 08 - iC n2,4
Fraiverlr(fondadon:without a signed waiver from the tabled of the request,a complete criminal Misery rernld may not
be relatable,per Code ofIawn,Chapter 691.7,For maul*criminal history record(arerteation,as allowed by law,always
obtain a waiver shmatereftem the eublrrt of the request. _ _
' Waiver Release:Ihereby Pe gonfalon Ibrdm.bnowp eeling Weil 10 conduct on tows withal billowy l rbekvdh the DiviionetcriaWl
Ir+gdarlion(OM anynimlad hInewdm Inenmthat km.hnelneBby 1h0 DCI amyho mleaadc&lowedbylmr.
/� G
WmlerSignalare: Si'? ',b� .”-
I`onwe Criminal History Record Check Results °Mumeniii
(�
As of — t ILO 43 ,a search of the provided name and date of birth revealed:
1,,Er— No Iowa Criminal History Record found with DCI
o Iowa Criminal History Record attached,DCI#1 •
.
DCI Initials M
DCI.77(08/29/10)
Received Time Aug. 29. 2013 2:46PM No. 4328
lg., Iowa Department of Transportation
Office of Driver Services (FOIl Free)800-532-11211't}Hmt 9204,Des Moines,IA 50306-9204 515-2 -9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/29/2013 DL/ID#: 431XX7973 (IA) Customer#: 4283012
Name: Kober,Tara Ashlee Class: D ID Status: None
Address: 101 BICKFORD DR Audit#: 7292821 DL Status: VAL
Issue Date: 08/29/2013 CDL Status: None
City/State: WEST BRANCH, IA Expiration Date: 10/12/2018 CDL Cert Status: None
523589572
Endorsements: 3 CDL Med Status: None
Mailing Address: 101 BICKFORD DR Restrictions: NONE Restriction None
Date of Birth: 10/12/1985 Supplement:
Mailing City/State: WEST BRANCH,IA Sex: F
523589572
History Information '
Convictions
Citation Date Conviction Date ACD Explanation . . County . JUR
. _ . . frail to Obey Traffic Sign/Signal Johnson IIA
03/01/2009 '03/23/2009 �M 34 .....
09/20/2009 X10/09/2009. .,11364 LNo Insurance Card ,Johnson IA
09/20/2009 .10/09/2009 ;M14 /Fall to Obey Traffic Sign/SignalJohnson IA
12/11/2009 ;12/28/2009 ?M14 Fail to Obey Traffic Sign/Signal :Johnson IA
Accidents-Accident Involvement indicated does NOT mean the Individual was at fault or given a citation.
Accident Date ' Case Number JUR
12/11/2009 1541559 ;IA
Name: Kober,Tara Ashlee DL/ID:431XX7973
Pursuant to Iowa Code§321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I an'
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:
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t 8/29/2013
fw. IOWA I
e
0/2 eletera
,it p' v, Office of Driver Services
A hyf 611%
� Iowa Department of Transportation
Name: Kober,Tara Ashlee OL/ID:431XX7973
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