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HomeMy WebLinkAbout18-043 IDENTIFICATION NO. -011 .11M04 �� A r 1 (Office Use �►'4 w I:I 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 4 I 0 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) C 4.S it-ok-)Ski" 6t-rJ111 W'i 'fe-t/- 2. Address(REQUIRED) 00 t'Ju I 14,u-)— S.f Tot..- C/ L , T.? S.2 4 Q 3. Contact Information(REQUIRED) Email: `\1.4.) '405 Cell Phone:3i9 S '•/21 5— (Ail written communication sent via email) 4a. Driver's License expiration date (REQUIRED) ©(.! - 5 - 2 C Z.S- b.Taxicab Business Name(REQUIRED) Ye l tot., (' ' C 5. Prior experience in transportation of passengers: S t X Yec,vS e, itzt•–,Fes*. c.C_ ,1 .Te +-y I �. yam, 5 St14)44/..c— `etA CA_1 ��tt'!i ti h 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? NO-- Type of offense Where When N 6 >� a .:.{ What happened to the charge?(Circle one) o Convicted Dismissed Deferred Suspended Plead Guilty r the 7. Have you been arrested/charged with any traffic offenses in the last five years? ye S �;;5 Type of offense Where rrWhertrnn Sour. C,+ s i3. 203 What happened to the charge?(Circle one) Convicted Dismissed Deferred Suspended Other 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. Have you ever applied to be an 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 J027 AL Sr t17. issued on 01.�j..1c/")expiring on Otj,LS.,2%rL r . 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, 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date L(•2L) -7,L)1`1‘ STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by TO s-t 11n Ltd . s on this 20 day of or-► 0 ,, •Y S.MAYER Notary Publ�.in and or the S e of Iowa Is Commission `u ,., • ***************************************,k****Inft********** I have reviewed this application, DCI report, and the State certified driving record of this applicant and Ime determined that there is no information which would indicate that the issuance would be detrimental to the safe},] A9altfkar welfefof resi- dents of the City of Iowa City(Title 5, Chapter 2, City Code). i cam-[ o r. Expiratio e= e of j i license rn -v 97 ,eg C7 Sign-Pe of Police Chief or designee Date cs 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 Clq or designee Date ************************************************* ******************************************************************************************** Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAXIDRIVBADGEAPPL92018amended.DOC 04/2018 • ��Apr••`9.. 2018. 9:•34A1A.. Div of Criminal Investigation Ay)3 No. 8239 P. 1/1 21002 OF xovv -1::...I;,. ,? _•4o-,,,;i,,-.,-.1k,,--- Criminal History Record Check . r-. ' Request Form ,'N,:��, .,r ' . • rtl;,. -,,..> DCI Account Number: 9967..F ,, (If applicable) To: Iowa Division of Criminal Investigation Support Operations Bureau, a"Floor From: Yellow Cab•of Tows,Gity 215 E. 7`"Street P.O.Box 4�8 Des Moines,Iowa 50319 (515)725.6066 Iowa City, IA: 52244 • (515)725-6080 Fax - .. • (319)338-9777 Phone: FAX (319)339-7302 I am re uestin an Iowa Criminal Histo Record Cheek on: Last Name Jmandaory) . - First Name(mandatary) IVIiddleie rccdmrncnded) -, -a511-0w31e ..Sc}Sep t. • OA 1V- Yate of Birth (mandatory) Gelid el'(mandatory) 'SO dal'Security Number(recommended), I(1 . 25- - /27 lfiMa)e ak�ertlaie l611• S.z_ 332.-) Waiver Information:Without a signed waiver from the subject ofthe•re gµest, a complete criminal Itigory record may not be releasable,per Code of Iowa,Chapter 692.2. For complete criminal history-record inform ;at ved linlitv,always obtain a waiver rignatUre from the subject of the request. • „ 2"< O 1 Waiver Release:I hereby jive pamlatIon for the above tcquesting official to conduct an Iowa eriminal history record dfliFtvith the Divisiyyf riminal Investigation(DO. My criminal history data ooncemease ing• e that is mainreined by the D(1 miry be reld as allowed by la ' rc c -0 t •a 11 � r —� Waiver Slgnalare: ( � N Q —.no - , .d Iowa Criminal Uistor�y Record Check Resi�l•I � ,.. (DCI maenlyj • As of LI —kr ,a search of the provided name and date of birth revealed- .� • , , •l Ci----1/0 Iowa Criminal Histoiy Record found with DCX : • -li • 0 Iowa Criminal History Record attached, DCI# So DCI initials Cl DCI-77 (08/2S/10) Received Time Apr, 5. 2018 6: 09AM No. 6)5) + ARTS Page 1 of 1 Pligifill. lOWADOT Driver & Identification Services P.O. Box 9204, Des Moines, IA 50306-9204 Certified Abstract of Driving Record Inquiry Date: 4/20/2018 DL/ID#: 127AC8472(IA) CDL Permit Class: None Customer#: 5231945 Class: D CDL Permit Issue None Date: Name: Laskowski,Joseph Walter Audit#: 1761773 CDL Permit None Expiration Date: Address: 836 WALNUT ST Issue Date: 04/21/2017 CDL Permit None Endorsements: Expiration Date: 04/25/2025 CDL Permit None Restrictions: City/State: IOWA CITY,IA 522403340 Endorsements: Chauffeur 3 ID Status: None Mailing 836 WALNUT ST Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY,IA 522403340 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 4/25/1973 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions rsa Citation Date Conviction Date ACD Explanation CD. JU JIM 09/13/2013 10/02/2013 S93 Speed j�IA-0 Jot JDn Accidents-Accident involvement indicated does NOT mean the individual was at fault or a enation Accident Date JUR Case Number '< MC CD 0 09/13/2013 IA 7571415. N Name: Laskowski,Joseph Walter DL/ID: 127AC8472 (IA) J Pursuant to Iowa Code §321.10, I, Darcy Doty, Driver&Identification Services, Iowa Department of Transportation,do hereby certify that I am the custodian of the records held by the Driver&Identification 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: ,�fN'OF 744 , PHSoy 4/20/2018 0 I 49(90/2V_ daYtn_ \4% U,E?' Driver&Identification Services i Doc Iowa Department of Transportation Name: Laskowski,Joseph Walter DL/ID: 127AC8472 (IA) httn•//17') ')Q ')Gd S5/firinaro/rc+. n,-+r•/..,,.,+,-..�, 1.:,.*„«,.L.,...+:fi,,,7,1.:..: .7 ,. ---. a I,sni'....n