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Home My WebLink About13-126 Authorization Number /3 - +`aw f r 1 (Office Use Only) .:III .14 CO BAT 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 t ddle Las l S 1 1. Name —t: ;-� L'1 2. MailingAddress � - `J0 X 0 3. Telephone: Home 3 / - h L?0 / / 3 k/ Other: 4. Prior experience in transportation of passengers: / y es:-Lr-s 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? r S Type of offense nWhere When 0,ti,5 c- j !\ /VL.E-4: 1 3 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? t,1 U Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? t'\ Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? (l c 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 herey certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numbest 3 9 -z...--2_. 3 7 y -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 1 t;, _/ . 1r/5, Date b.�-1 _ (3 STATE OF IOWA ) COUNTY OF JOHNSON ) T "--- Sulokscribed and s t before me by • \ e- -------1 (. Lk ( On this 7-“\-- day of atac KELLIE K.TUTTLE /� t'_C(/� /LC �{' oi''� commission Numb•r 221819 Notary Public in and for the State of Iowa I My C• ma iii Lco — s/12., _ 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). gna ur Police Chief or designee ate 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. Signature of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width) and 51/2" (height)and prominently displayed to all passengers. *******************************.******.*.****************************.************************************************************************** Office Use Only Approved application DCI report State certified driving record Website update derkitaxidrivbadgeapp2010.doc 03/2013 1' Iowa Department of Transportation Jo Office of Driver Services {foil Free)80G-532-1121 I PFJ Sox 1204, € es Moines, LA 503115-9204 515-244-9124 FAX:515.239-183f Certified Abstract of Driving Record Inquiry Date: 6/5/2013 DL/ID#: 959ZZ3747(IA) Customer#: 3363878 Name: Ulstad,Jeffrey Alan Class: D ID Status: None Address: 1131 3RD AVE APT Audit#: 5381185 DL Status: VAL 4B Issue Date: 07/20/2011 CDL Status: None City/State: IOWA CITY,IA Expiration Date: 09/23/2013 CDL Cert Status: None 522402013 Endorsements: 3 CDL Med Status: None Mailing Address: PO BOX 810 Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 9/23/1954 Mailing IOWA CITY, IA Sex: NI city/State: 522440810 History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JIJR 12/11/2008 485651 IA 01/14/2010 549670 IA Name: Ulstad,Jeffrey Alan DL/ID: 959ZZ3747 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: " I iir �lliii 6/5/2013 IOWA 4 5 (1L s ar caceitero_4 lh �•°RIa .=7` Office of Driver Services 41�t'twxygp�a Iowa Department of Transporation •oi 2.�un• . 3. 2013 10:05AM;ab0Div of Criminal Investigation -3193382708 No. 4923' P. 1/2 • IUt■▪ • - .. , • STATE OF IOWA :::,,ni y g Criminal History Record Check f' * •ih t t� ;riA " Request Forth < \ „ 7 • iY. • �'e 1,1 xi +�. • :e rt 1, , • ' - DCI Account ' 9967-F or epplicabic) To: Iowa Division of Criminal Investitatioa Prom: Yellow Cab of Iowa City Support Operations Bureau,1"Floor ' . P.O.Box 428, • 215 E,Tb Street , • .Des Moines,Iowa 50119 ' Towa City, IA. 52244 ' (515)725-6066 , + (515)725.6060 Fax I (319)338-9777 ' Phone: ten: (319)339-7302 • I am requesting an Iowa Criminal History Record Check on: Last Name(madman.) ' I First Name(mandemq) Middle Name(recommended) Date of Birth(menda,ary•) Gender(mandatory) Socjal•Security Number(sxommcnded) l — -- lJ 1.6 LJMak ❑Female Lt —1 7 1_,•- (D a.) 5r 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.Por complete criminal history record ihforniation,as allowed by law;always obtain a waiver signature from the suNecl oftbe request- . Waiver Release:)hereby give pemnssien for the above requesting°theist to can duct anima csiminnl history mord check with the Division orCriminal Investigation(DC1). My uiminal blstort data concem_ne no thet is meinmind by the DC/may be teteeacd es'Wowed by law,_ --__ • • Waiver Signature: AA a I L jam/ I S &Iowa Criminal History Record Check Results (DCL use only) As of -3 /.3 , a search of the provided name and date of birth revealed: Cl No Iowa Criminal History Record found with DCI ' Iowa Criminal History Record attached,DCI# 7 7io2(. DCI initials ) H • DCI-77(05125!)0) • Received Time May. 29. 2013 12:49PM No, 5035 Jun. 3. 2013 10:06AM Div of Criminal Investigation No. 4923 P. 2/2 IOWA CRIMINAL HISTORY DCI 00517960 NON CONVICTION PAGE 1 OF 1 DATE PRINTED- • 2013/06/03 • DCI:00517960 NAME: ULSTAD,JEFF ULSTAD,JEFFREY ALAN DOE SEX RAC HGT WGT EYE HAIR 5101 POB 19540923 M W 603 210 ELU GRY FAR IA ADDITIONAL IDENTIFTERS SC R KNEE CCH RECORD t+'' 01 ARRESTED 19960220 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA708-1 ASSAULT CAUSING INJURY TRK{{: 022590301 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE IA708-1 ASSAULT CHARGE CLASS: NON CONVICTION TRK#: 022590301 SENTENCE DISP EFF DAT DEFERRED JUDGEMENT 19960815 DISCHARGED FROM 19970506 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED EY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, EUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON-LAW ENFORCEMENT AGENCIES 21 THE DCI., IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION