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CITY OF IOWA CITY
410 East Washington Strect
Iowa City, Iowa 52240-1826
(3191356-5040
(319)356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO._ "D L4 I
(Orrice use only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
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3. Contact Information (REQUIRED) Email: r(J
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4a. Driver's License expiration date (REQUIRED)
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b. Taxicab Business Name (REQUIRED) Mu f'C ()-e>
Middle�u 1 I/
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Last b-0 W^
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*"'I'd�0'o l.(a"gellPhone:-Jlef-4CAO .A197
iication sent via email)
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5. Prior experience in transportation of passenger. _ Y -g 00
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?Y-e $—
Typs of offen e t Where
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What happened to the charge? (Circle one)
When
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Convicted Dismissed Deferred Suspend Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? S
Type of offense
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Where
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When
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guil Other
B. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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Tvoe of offense Where a WhdZ
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, pleas�idgohe nzMs)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHI&%EVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0712016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
herebyy certify th t I ave issued to me by the Iowa De rtmggnt of Transportati n valid Driver's license number
2 �— - C t 7 `a 6 issued on 3-155) P expiring on 1 0. �C 1 . I understand that it I
falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver is granted, to comply at all
times with all of the pro 'cion f Tfile 5 Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
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Signature of Applice
— Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
before
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day of
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no inf j n which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of th ity of 1 City (Title 5, Chapter 2, City Code).
Expir ion d of 'vers icense 1////// Z f
Q!---4 Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
ign lure of City Cler c designee Dale
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Office Use Only .�
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Approved application i►
DCI report QOM&
State certified driving record 1
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Office of Driver Services
PO Dox 9204 1 Des Moines, IA 50306-9204
Phone. 515-244-9124 1 800-532-1121 I Fax 515-239-1837
www.ivwadotgov
Certified Abstract of Driving Record
Inquiry Date:
8/29/2017
DL/ID #:
239CC5786 (IA)
CDL Permit Class:
None
Customer #:
2159919
Class:
B
CDL Permit Issue
None
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Date:
Name:
Brown, Nathan Randall
Audit #:
9858247
CDL Permit
None
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OiiIVE�
iaaof Driver Services
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Expiration Date:
Address:
3175 HIGHWAY 22 LOT 22
Issue Date:
03/15/2016
CDL Permit
None
Endorsements:
Expiration Date:
03/06/2021
CDL Permit
None
Restrictions:
City/State:
RIVERSIDE, IA 523279601
Endorsements:
NONE
ID Status:
None
Mailing
3175 HIGHWAY 22 LOT 22
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
VAL
Mailing
RIVERSIDE, IA 523279601
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
3/6/1980
CDL Cert Status:
Excepted Interstate
Sex:
M
CDL Med Status:
None
History Information
Convictions
Citation Date Conviction Date ACD explanation JUR County
09/11/2014 01/08/2015 M14 IFallto Obey Traffic Sign/Signal SIA Johnson
Accidents - Accident Involvement Indicated does NOT mean the individual was at fault or given a citation.
Accident Date JUR Case Number
10/04/2013 IA 1760447
Name: Brown, Nathan Randall DL/10: 239CC5786 (IA)
Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, 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,
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In witness whereof, I have caused my signature and the seal of the Department
to be set upon this document, at Any, Ioviilhls dsiiiiiiis
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8/29/2017
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Transportation
Departme tansportation
Name: Brown, Nathan Randall DL/ID: 239CC5786 (IA)
Aug. 3. 2017 2:53PM Div of Criminal Investigation
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STATE OF IOWA
Criminal Hletory Record Check
Request Form
To; laws Dev41Ya of Criminal loveatIPUM
Support opersdoer llaraaa, 1" Floor
115 L T street
Da Molnu, Iowa 60119
SM 71e -M66 --- — —
(511j 715 6080 Fa c
No. 4111 P. 1/6
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Last Name
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First Na°rc
I1'lddM Name
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Geador
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lad & ithout a low& Chaptera66ed 911. Foriver te the bcrimlaind d history record a/onmation, *cowed byinal history �bdw, a1w11"
Waiver injAble,
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apbin a waiver rare trythe sub ecl of the aat. _
Waiver Release: l hm* sive p■—u fw dw *re f 4 n otacW m Gonda .l tewe MillAW Abay leoonl Ned with
In+M11y1b,1(DCI). A^Y uMJed Mnny dw �onM�or hj.LoL�de�d b/ Qr oCl mey Ee nllewa u dM1d y' 4w.
tln Divhim orcNolast
Waiversit"Urst
12M critniviLl History Record Check Results
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As of ;3 - t�� a semi, (if the provided nnrne and data of birth roweled:
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❑ No Iowa Criminal History Record found with UCI
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Iowa Criminal History Record attached, DCI # <�6
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DCI
DOM (OV2910)
Received Time Jul. 28. 2017 6:36PM No. 3762
Aug. 3. 2017 2:53PM Div of Criminal Investigation
No.4111 P. 2/6
IOWA CRIMINAL HISTORY DCI 00682738
MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1
DATE PRINTED -
2017/08/03
DCI:00882738
NAME: EROWN,NATHAN RANDALL
DOB SEX RAC HOT HOT EYE HAIR SKN POB
19800306 M W 603 200 BLU BRO FAR IA
ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y
SC R "BE
TAT CHEST
TAT L ARM
TAT R ARM
TAT UL ARM
CCH RECORD r'•
01 ARRZBTED/TAKEN INTO CUSTODY 20091115
AGENCY: IA0520200 IOWA CITY PD
CHARGE NO- 01 IA STATUTE IA708.2A(2)(H)
DOIRSTIC ASU#R ASSAULT WITHOUT INTEiT CAUSING INJURY
TRK#: IA0066I01
COURT DISPOSITION
AGENCY: IA052015J JOHNSON CO DIST COURT
COUNT NO- OI IA STATUTE: IA723,4(1)
DISORDRRLY CONDUCT - FIGHTINO OR VIOLENT IRRAVIOR
COURT CASE ID: 06521 SRCROB9015
CHARGE CLASS: MISDEMEANOR CONVICTION
TRK#: 1AD086101
RESTITUTION
SENTENCE DISP EFF DAT
FINE $100 20100409
AN ARREST WITHOUT DISPOSITION 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 HE RELEASED TO NON -LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINORRPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SU13JRCT OF YOUR INQUIRY.
/
DIVISION OF CRIMINAL INVESTIGATION
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