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Home My WebLink About14-239 Authorization Number J4-1 --7)(1 r (Office Use Only) AOIwIgi APPLICATION FOR TAXI/ MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m.to 3 p.m., Monday—Friday.) 410 East Washington Street Iowa City,Iowa 52240-1826 Failure to complete the "required"information will result in denial of the application 1',_9) 356-5040 lo�2 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) Kere ft Lo-re vi 2-0 5c�rn��i 2. Mailing Address (REQUIRED) 4s V N hobrt'lfe Si, Apt. ( ) / NorTLL►be►''I\H , So2,3/7 3. Contact Information (REQUIRED) Email: ket'e-00(9ye,heo•Cam CellPhone:,31`x'333. 24E-2 4. Prior experience in transportation of passengers: --- (4"acV c+ S (v rScm J2I";c,14e_ tJv i(2,.2-,A3 ay.'` d t p�ovJm�.�� S 1%,,n ?,,e le --VAs c,�J 194c k 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? h D Type of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? v1C: Type of Offense Where When rU 1 7. Have you been convicted of any traffic offenses in the last five years? in U C)- ry Type of offense Where Wie C.7� =�.1 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 1n0 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) V1(2 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND I1kik 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) 09/2014 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license nuniber CbS7U 1/ 1 °! . I understand that if I falsely answer any questions in this application, that this- application hisapplication 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) 7 Signature of Applican• ► .: '4 _ Date/d' a3` /Li 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. c\.; STATE OF IOWA2 cJ COUNTY OF JOI NSO(t CD f� Subscribed and -sworn to before me by Ke(c -1 L. G . fj r•.wt . On this 21\ rO day of Or IrOlfICLA- 401" • . J , 4',. WENDY S.MAYER Notary Publi.tn and for the Sta{:. of low_ ~ t uommisslon Nurrner rfi9g2A r` r • My Commis 'on Expnes ***************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). W / (-0' /2 ) i L/ Sig . ir- . 'olice 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 des "nee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width) and 5 1/2" (height) and prominently displayed to all passengers. ....**...**............................**......*................................................................................................ Office Use Only Approved application DCI report State certified driving record Website update ClerkiTAXIDRIVBADGEAPPL92O14amended.DOC 09/2014 Oct. 22. 20144 9: 24AM1 Div of Criminal Investigation No. 2423 P. 10 i ,• LVI 1i . iiin vitt vrQin UI Ly ni Luna t.ltY IVU. )).)3 1. L • • 4,--yer"--- s,i, fi. STATE 011? IOWA . ' `--n� arF4 'j ..m,,. � ♦fir.y ' Criminal( Ifk story Record Check - :651:'3 '1- -..„ ,'7..--01::;17:r--1 it Request Form ',, ,u_,,�, . .„... DCT Account Number: 1/00., - F (itepplicablc) To: Iowa Division of Criminal Investigation From: City of Iowa Cly Support Operations Bureau,1"Floor City Cleric's Office 215 E.711'Street • 4101 .Washington Street Des Moines,Xowa 50319 (515)725-6066 Iowa City, IA 52240 (61S)725-6080 Fax rhohe; 319-356-5041 b w • Fax, •X' o 319-356-5497 c - —+ C-)-< w s-- Yam requestin: an Iowa Criminal History Record Check on: -1-,-. 3}y Last Name(mandatory) Pint Name (mandatory Middle Narita( '• tiers,;;; '_..2 1} JamoC NCire, T1 (-_.ahem zu Date of Birth (mandato Gender(%mandator,, Social SeeUri number recommended -- b 2 0 ✓ Ef ale ❑Female 5zt ` q-ar572 Waiver information:Without a signed waiver from the subject of the request,a complete criminal history record may not he releasable,per Code of Iowa,Chapter 692,2.For complete criminal history record information,as allowed by law,always obtain a waiver signature from the subject of the request. Waiver Releaser I hereby give permission for the above requesting official to conduct an fowl criminal history mord chock with IhaDivision of Criminal Investigation(DCI). Any criminal history data cor�� r that is maintained by the DCf may he released as allowed by law. / 1 Waiver Signature:. _ - /740.4e.gese..-) �C . e J(31wa Criminal fflistory Record Check tS (DCTSCs4only) As of ii0 7-? j y , a search of the provided name and date of birth revealed; • 4. No Iowa Criminal History Record found with DCI • I'•1 0 Iowa Criminal History Record attached,DCI# DCI,initials• iStJ Received Time-7Ocf."1]”014 12; 17PM No. 2135 • c OT SMARTER I SIMPLER I CUSTOMER DRIVEN wvvwiowadot gov Office of Driver Services. PO Box 9204!Des Moines,IA 50306-9204 Phone:515-244-9124 1800-532-1121 I Fax:515-239-1837 www_iowadot.gov Certified Abstract of Driving Record Inquiry Date: 10/15/2014 DL/ID #: 505AG9119 (IA) Customer#: 5807130 Name: Samoa, Kereti Lorenzo Class: C ID Status: None Liamatua Address: 450 N DUBUQUE ST APT B2 Audit#: 5059119 DL Status: VAL Issue Date: 03/04/2011 CDL Status: None City/State: NORTH LIBERTY, IA 52317 Expiration Date: 09/02/2016 CDL Cert Status: None Endorsements: NONE CDL Med Status: None Mailing Address: 450 N DUBUQUE ST APT B2 Restrictions: NONE Restriction None Date of Birth: 9/2/1988 Supplement: Mailing City/State: NORTH LIBERTY, IA 52317 Sex: M History Information CLEAR DRIVING RECORD Name: Samoa, Keret' Lorenzo Liamatua DL/ID: 505AG9119 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: fofe 4, 10/15/2014 Bjr'••••••'• Office of Driver Services C.J *`**.* � Iowa Department of Transportation —152 7.<1 r �__�. C]• f) Name: Samoa, Kereti Lorenzo Liamatua DL/ID: 505AG9119 ��