HomeMy WebLinkAbout13-042CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
JJ ,,First
1. Name iel/l-
2. Mailing Address
3. Telephone: Hor
4. Prior experience in transportation of
Authorization Number. / 3 —
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Other:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
(Office Use Only)
6. Have yo een 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
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. Hake 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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derkfl dnvbadg 09/2012
I he certi h t I h�yav Issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1 N T� . 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) /� o
Signature of 0 Date Z 0
STATE OF IOWA )
COUNTY OF JOHNSON ) / / /
S bscr'bed and sworn to before me by f�tC lelLle_ On this day of
L 12 LA 201--2D
p0r, KELLIE K. TUTTLE
o ,s Ion Number 221819 Notary Public in and for the State of Iowa
�A/ OT i5 I
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 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.
Signature of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
'�') -"-13
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
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4
Iowa Department of Transportation
Office of Driver Services (Toll Free) 800332-1121
PO Box 9204, Des Moines, IA 50300-9204 515-244-9124
1*0 FAX: 515-2394837
Certified Abstract of Driving Record
Inquiry Date:
2/26/2013
DL/ID #:
636MM7805 (IA)
Customer #:
1621790
Name:
Lubaroff, Helene Marie
Class:
D
ID Status:
None
Address:
1316 MUSCATINE AVE
Audit #:
4102117
DL Status:
VAL
Issue Date:
02/16/2010
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
02/03/2014
CDL Cert
None
522403219
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1316 MUSCATINE AVE
Restrictions:
NONE
Restriction
None
Date of Birth:
2/3/1966
Supplement:
Mailing City/State: IOWA CIN, IA
Sex:
F
522403219
History Information
CLEAR DRIVING RECORD
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
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:
;:-•""••:;�/'
2/26/2013
IOWA Nwl,
r
D. 0. T.
Office of Driver Services
......
Iowa Department of Transportation
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
�oz,Feb.21_� 2013J811 26AM Div of Criminal Investigation No.4066
I DCI IOWA
STATE OF IOWA
Criminal History Record Check
Request Form a
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As of oZ a-: it search of the provided name and date of birth revealed:
No Iowa Criminal fiigtory Record found with DCI
Iowa Cfllnlnal Hietory Rewtd att chcel, DC1 #All
D61 initials
DCI 77 (0825/10)
Received Time Feb. 8, 2013 8:07PM No.4110