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Home My WebLink About14-231 Authorization Number /'—a 31 " t 1 (Office Use Only) --Zs" ®Ar mall I ,41MAT 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 = 'fovea Sity. Iowa 52240-1826 Failure to complete the "required"information will result in denial of the application (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) N E 1< 2. Mailing Address (REQUIRED) Il o7 So irk SI": Otto n 'Jc— T A 5250 3. Contact Information (REQUIRED) Email: SG,4 (tJtlh27St-ex-1HA1( .aat') Cell Phone: g43'y-53 63t2 4. Prior experience in transportation of passengers: re--S CCE 1--(A) e v a` V c t \ 'e y Ca: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /// Type of offense Where When 6. Have you b 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? /v 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) 10) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE 01FIf=(? DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHEP-REV.EW You must apply for an individual Department of Criminal Investigation Report(form availab ; poll quest)., (OVER FOR REQUIRED SIGNATURE AND NOTARY) ca PI -S5 �~ 09/2014 trtiereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number l e11 1/( (`(q N K . 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) r,' Signature of Applicant - �� Date lb l6 / f 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. ************************************************************************************************************************************************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subcrcrib d and sworn to before me by ( I e.n r1 C(.� r }L . On this )t`o` L day of 14. C -CIDbr , 0-0,4 �Ir( KELLIE K.TUTTLE Notary Public in and for the State of Iowa c„i,,,,„,,,,,,,r,,.141,cr 221819 ; My Ga/ jn Expires ************************************************* *** ***************************************************************************************** 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). IPA. /0A67/(71 Signature .—o Ic-r7''lef or designee Date YOU ARE s 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. /m// / /6i Sign e of City Clerk or designee Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (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 C IerWTAXIDRIVBADGEAPPL92014amended.DOC 09/2014 Ocrt.,,14. 2014 9 :49AM Div of Criminal Investigation �o.,191i1 FP. �1/1 Cr Oct. 7. 2014 12:h/I'M City Clerk — City of Iowa City ■ ■ ■ STATE OF ]IOWA <-.� ►if F 41";b11,% rregaa - -1- IiiirtT- lRequest, Fortin � ,l `>1:- -.‹. (, „--. _ t ” DCI Acoowit Number `TUG —f- (itBp➢Ilcable) To: Iowa Division of Criminal Investigation awn; City of Iowa City Support Operations Bureau,('`?Floor City Clerk's Office 215 T„71"Street 410 E Woahington Street Des Moines,IowA 50319 . (51S)725-6066 Iowa City, IA 52240 _ (515)7254080 Fax ' phone; 319-356-5041 • 'ax: 319-356-5497 I am requesting an Iowa Criminal Nistoiy Record Check on: Last Name tl,andete s ]First Name(mandatory) Middle Name(recommended) C.,(a )r K0____. . C Vl V CV' i e__ Date of Birth(mandatory) Gender mandatory) ' Nodal Security Number(recommended) 5y;///..7 , Elbetile ❑Female /4-3—C 1 3 32q q Waiver Information:Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 692,2.p'or complete criminal history record Information,as allowed by law,always obtain a waiver signature from the subject olC the re•Uest. . • WaIVer RefeaSe:I hereby give permission for the above requesting official to conduct en rows criminal history record check with the Division of Criminal investigation(DCD, My viminal history data concerning en i tit l iolaieed by the DCI ;t o Mies a allow law. Waiver Signature: r 6< , =�_ -_\ �, 1[owa Crimina' History Record Check Results (Dcluse,only) As of 1 0 1 1 `1 , a search of the provided name and date of birth revealed; ` '; -• t rA` No Iowa,Criminal History Record found with,DCT ' • IND Li Iowa Criminal Histone'Record attached,DCI# • i - Del initials -- t ".... ,,,,,iiio ,,,, ,,,,„,,,,, ,,,t, ,„,. ,,,, -s, ,,:„.„., SMARTER 1 SIMPLER I CUSTOMER DRIVEN ot„,„,,,,,_,. wv,Amiowadot gav Office of Driver Services PO Box 9204 i Des Moines.fA 50306-9204 Phone:515-244-9124 j 800-532-1121 (Fax:51 9-1837 -•-www.io iadot.gov CD ar.:7 S - Certified Abstract of Driving Record -5~ """ �� < �� :7-7-1C-) =— Inquiry Date: 10/7/2014 DL/ID#: 813AK7246(IA) Customer.#{` 641899 S r: u Name: Clark,Glenn Eric Class: AID Status:..__1T Nene w Address: 1107 SOUTH ST Audit#: 8293517 DL Status:---- VaD Issue Date: 07/25/2014 CDL Status: Vj City/State: OTTUMWA, IA 525015452 Expiration 05/02/2019 CDL Cert Status: Non-Excepted Interstate Date: Endorsements: NONE CDL Med Status: Certified Mailing Address: 1107 SOUTH ST Restrictions: NONE Restriction None Date of Birth: 5/2/1976 Supplement: Mailing City/State: OTTUMWA, IA 525015452 Sex: M CDL Medical Examiner's Certificate Certificate Specifics Explanations Medical Examiner First Name Brian Medical Examiner Middle Name Keith Medical Examiner Last Name Shedek Medical Examiner License Number 3990 Medical Examiner National Registry Number 1185209132 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 369-8153 Medical Examiner Type Osteopathic Doctor Medical Certificate Issued Date 06/02/2014 Medical Certificate Expiration Date 06/02/2015 Date Added to CDLIS Driving Record 07/25/2014 History Information CLEAR DRIVING RECORD Name: Clark, Glenn Eric DL/ID: 813AK7246 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: %%%%%%%%%% -='-sitEr.o 04:* IOWA :mst. 10/7/2014