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HomeMy WebLinkAbout18-044 IDENTIFICATION NO. f -DV II + 1 r 1 (Office Use Only) fta AIM Irlif APPLICATION FOR TAXICAB/MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m.to 3 p.m., Monday-Friday) CITY OF IOWA CITY 410 East Washington Street Failure to complete the "required"information will result in denial of the application Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name(REQUIRED) -Xlr^c` , C -e ( /1/`Ai 2. Address (REQUIRED) 2 2- 3C? /C--27/1 S Xrtti : 3 ((Otc1 f t'-//fr 1.1 5 2 2 44 / 3. Contact Information (REQUIRED) Email: Suroc . O'/e i-.cr rY.Cu. Cell Phone:(c/g1) 42 3 -602 7 (All written communiction sent via email) 4a. Driver's License expiration date (REQUIRED) C//22-/ 2. 22 4-- b. Taxicab Business Name (REQUIRED) Ye/4_1w' C'C!6 /cJL 0 Cid 5. Prior experience in transportation of passengers: 4 , 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested /charged with any traffic offenses in the last five years? Type of offense Where When /t//,/ What happened to the charge?(Circle one) Convicted Dismissed Deferred Suspended. PI� c��tufi1 Other 8. Has your driver's license or chauffeur's license been suspended or revoked maiatithid ears? Type of offense Where Zj ;� guy EZ 4Gdn /V// 0911 9. Have you ever applied to be n,Iowa City taxi driver using a different name? If yes, please provide the name(s) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 • ' APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 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). I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number f SCS /V CJ 5 33 issued on OYi 2/i 7 expiring on a!/22/202y' . I understand that if I falsely answer any questions in this application, that this application may be denied. I agree that in making this application, 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date 9'-1 f 2 3/ ) ***********************************i* **Ir*1r**#*#fi#*###i *********************** **************#*********AAAA..**#N STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by ) '4 R,� G.,c 0 1),L,_) on this 0/3 day of 461 Zo(r`� 4 k ` � ,r WENDY S MAYER .0011 �P J C'S-a Commission Number 729428 Notary Pu c in and for the St ,b of low kil...0M111531911 Qpnns I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi- dents of the City of Iowa City(Title 5, Chapter 2, City Code). Expiration d. - .f - •= license 01-Z1-lc( 1.7 4y-z3-4 Sign. Pe of Police Chief or designee 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. / • - — - Sig :ture of City Cl- k . designeei�-Iian '. Date 8310 Alta **********************************************A A A A AAA**H******************************#**#*****#*********#******************************#****** Office Use OVI :g W4 CZ Approved application t` DCI report State certified driving record Website update _ Clerk:DVIDRIVBADGEAPPL92018arne'ded.DOC 04/2018 r , Iowa Department of Transportation —�. O(ilce of Drover Servpces (Tar Free)800-532-1121 PO Box 9204,Des Moines, IA 50306-9204 515-244-9124 FAX:515-239.1837 Certified Abstract of Driving Record Inquiry Date: 4/11/2018 DL/ID#: 180AN9333(IA) Customer#: 6631497 Name: Sarow, Manuel Class: A ID Status: None Address: 2230 10TH ST APT Audit#: 1809333 DL Status: VAL 3 Issue Date: 05/12/2017 CDL Status: VAL City/State: CORALVILLE, IA Expiration Date: 09/22/2024 CDL Cert Status: Non-Excepted 522411351 Interstate Endorsements: Tank, Double/Triple CDL Med Status: Certified Trailers Mailing Address: 2230 10TH ST APT Restrictions: NONE Restriction None 3 Supplement: Date of Birth: 09/22/1986 Mailing CORALVILLE,IA Sex: M City/State: 522411351 CDL Medical Examiner's Certificate Certificate Specifics Explanations Medical Examiner First Name Claudia Medical Examiner Middle Name Lynn Medical Examiner Last Name Corwin Medical Examiner License Number 29261 Medical Examiner National Registry Number 8795856463 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 356-3335 Medical Examiner Type Medical Doctor Medical Certificate Issued Date 05/15/2017 Medical Certificate Expiration Date 05/15/2019 Date Added to CDLIS Driving Record 05/19/2017 History Informatip1ji '}k113 VMO IZ8313 A113 CLEAR DRIVING R,IC,IiiRA EZ Hdn BIOZ Name:Sarow, Manuel DL/ID: 180AN9333Cl 3 i i Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do ,Apr,�19.��20163;�5: 02PM,CabDiv of Criminal Investigation No, 9340 P.I�a>319 338 Noun x1,0021002 r , STATE OF IOWA .,„$ Criminal History Record Check • < : •: v_ Request Form • DCI Account Number: 9967-F (If apoileablo) To: Iowa Division of Criminal Investigation From: Xe11ow Cab of Iowa City Support Operations Bureau,1”Floor P.O.Box 428 21s E:711 Street Des Moines,Iowa 50319 (515)725- 066 Iowa City,IA. 52Zd4 (515)723-6080 Fax (319)3389777 Phone; put (31.9)339.7302 I am r uestin an lova(criminal Histo Record Chock on: Lariat Name imandatait Firat Name rnandsto Middle Name(rocommooeed) 5c,,(r-a-oY / c/r z rs e( it///‘ Date of Birth(mead ) Lender(martdat• Social Sece ri Nu ber recommended....„ 24'/22 /g6 r7 Msale ©I+emaloe • Waiver Information.'Without a signed waiver irotn the subject of the request,a complete criminal history rec.ord may not be releasable,per Code of Iowa,Chapter 6924.For complete criminal history record information.,as allowed by law,always obtain a waiver el stare from the etlb ect of the r uest. Waiver Rdeasc;1 hereby give pennlaaioo for the abvvo roquestint ottloial tO conduct an lows orirnlnal hlstory reposd check with Ors Division of Criminal lnwtS119.tlon(DCI), M y crimirrat b(stOry due oonoerningme that is maintained by tic DC1 may>x rcloated,as allowed by law. Wah'er Si'ibrlurre: 9�' rXrL���m al E stodgy R�corc� Chef Renu (DCI use only) As of Li- I I ` i D a search of the provided name and date gfbirth re,'eaIed; r ` 11 No Iowa/Criminal History Record found with DCI 'vrJ't`1 U I 'A113 \NO. ',13-13 A113 Q Iowa Criminal History Record attached,DCI# ?,t1. _Liv C z 8dV C 1 az DCI initials= 31Th Ct. 3 1 I •d . • DCI.77(08/25/10) Received Time Apr, 17. 2016 10: 02AM No, 7479 •