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Home My WebLink About13-153 Authorization Number ) -- 15 1 (Office Use Only) -_.®� III •di Wei CCU PIT APPLICATION FOR TAXI DRIVER CITY OF IOWA CITY (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 First Middle Last 1. Name rt.,rtitcr LVA` K y L pfa Y FYI 2. Mailing Address Z LI t-&O I 3. Telephone: Home -3sO-9 Z-Z Other: 4. Prior experience in transportation of passengers: '{2-L�0 c--tPs o _.e kA.)('t G t T`( 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? N/rar Type of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? N-.)/ft Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? ‘42-`-- Type (2-SType of offense Where When pec t t 13 .-1--1- IO Cts v N1 1 31261 t k -1-Wk OPS_ - g etCK--LNC= te0AIOS01 ctL°ytz\( (0/0///&. 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /UM 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) 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) clerk/taxidrivbadg 03/2013 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number \ �2 NI J S`7 0 1 . 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 g _</ Date ' STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by Try ru7(. . On this Z 5 day of 2•x/7 / ° 4' SONDRAE FORT z Commission Number 159791 My Co�iesign Expires Notary Public 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). Signature of Police 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. Signatu e 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 clerk4ax,drivbadgeapp20'O.doc 03/2013 (F. Iowa Department of Transportation '` I tC.c b1: J: LH./ Certified Abstract of Driving Record Inquiry Date: 7/22/2013 DL/ID#: 432YY5707(IA) Customer#: 3875157 Name: Prymek,Donna Class: D ID Status: None Marie Address: 2175 KOUNTRY LW Audit#: 5453760 DL Status: VAL SE APT 1 Issue Date: 08/18/2011 CDL Status: None City/State: IOWA CITY,IA Expiration Date: 09/23/2015 CDL Cert Status: None 522409302 Endorsements: 3 CDL Med Status: None Mailing Address: 2175 KOUNTRY LN Restrictions: Corrective Lenses Restriction None SE APT 1 Supplement: Date of Birth: 9/23/1979 Mailing IOWA CITY,IA Sex: F City/State: 522409302 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 03/20/2011 03/23/2011 F04 Seat Belt Violation Linn IA 06/04/2012 06/19/2012 N82 Improper Backing Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 06/04/2012 688631 IA Name: Prymek, Donna Marie DL/ID:432YY5707 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: J ,. f" 7/22/2013 F ...... moi i i IOWA .' :�;D. d. T u„ -- , : fis rr' �f....... QRIYtF = Office of Driver Services Iowa Department of Transporation Name: Prymek,Donna Marie DL/ID:432YY5707 . Jul. 12. 2013 3:23PM Div of Criminal Investigation No. 0121 P. 1/1 ,.4:..05,*..,_. STATE OF IOWA ,4-.71,,,,. ::: Criminal Ristory Record Check Request Form .••,„y„o • • ACI Account Number: 99674 ('aPPllcabio) To: Iowa Division of Criminal Investigation From: Yellow Cab of Iowa Cltc . Support Operatloas Bureau,I"FloorB. 11.O..Box 42S 215 7'h Street • Lies Moines,Town 50319 , !arm city,IA. 52244 (S75)725.6066 (515)723-6080.Fax (319)338-9777 • • • Phones • Fax: (319)3394302 I am -.uestin:an Iowa Criminal Iilstmy Record Cheek on: Last Name oestst'ay) First Name wane*y•- •. Middle Nemoa.-c-.....mrsc,'-ierah • Date of Firtb(eamtmMy) .L.:At er E �:,,) • Reelui•Bee'udiy cumber pcieesseaaaa} um& ' %emote '� 14 T��^ t i Waiver lieformae' :without a signed waiver from the subject of the reques o complekcriminal history record xpay not uv■vaconuwa'y per Coda of Iowa,ampler 693,2.Fat complete Criminal bi3lory.yetolTl information, by law,always alw y as allowed 8 • , b.- iCawwaVFafJtrisl+�i aCu101inm The subject of the request - . a!verRefeast ibeabydm pam tsimi fot the above requesting official or concha en toua'aiminel blsnzy vend thetle with the Dlvtgen oft]ietek • Nvatigetion@Cir.Any errrniahistory data waoinsme that b ouireMae4 by the DM wry be Marled el aaowe4 by law. • rwalverSlgrraIire: Z . j "ow Criminal Histo Record Check-ltesulte • I- (p ,, (pa only) - As of —) 11 13 ,a sear. ch.of the nry}yided mane and dote ufbirth revealed- ! • No Iowa C.rmnIHistoxy1tecotd.found whi DCI I -• in Iowa Criminal-r.Iisloty Record attached,DCI"k . • DCI initials f ACI-77(08/25110) Received Time Jul. 10. 2013 9:17AM he.8628 •