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Home My WebLink About14-211 Authorization Number /1--/-- I -/— 02 j 1 1 (Office Use Only) --_. 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 (319) 356-5040 (319) 356-5497 FAX First Mid a Last 1. Name(REQUIRED) �� ) 2. Mailing Address(REQUIRED) \ "b�� L. - 0. \4 .• �► - 3. Contact Information (REQUIRED) Email: \C\AAj,, 1 gyar Cell Phone: 301 1 .. 1114 Qi 4. Prior experience in transportation of passengers: h 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? VN\6 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? Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When Vii►:.. 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? S Type of offense Where When \ \ \-1\-)' `1'SDN Qs) _ o 12,x12 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) • DEPARTMENT OF CRIMINAL INVESTIGATION(DCI) REPORT AND STATE C RTI D DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW :i`; You must apply for an individual Department of Criminal Investigation Report(form avaFla tle upon regte'§t). (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 number `7f_> - > i T . 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) Signature of Applicant `_ , Ih,� ' A ', .i it, Date (-)I(Qi 1 y 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 ) Subscribed and sworn to before me by S.e,4(vtctdr CH-e._ L. *D. ti Qw.Q . On this /L, day of + 4p g JOa ,e.9-7,71-1WFNOY S MAYER Notary Public in an�or the State of wa�� Commission Number 729428 s My Commission Expires *****s* w ******************************************************************************************************* 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). 1 ii( .......‘„ g- i6 -- i1/ Signat re o Police of 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. '72v1i- - k - L(il...) `/ /V Signature of City Clerk or designee Date 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 Clerk/TAXIDRIVBADGEAPPL92014amended.DOC 09/2014 097Sep. 13. 20142 2:43PM Div of Criminal Investigation (FAX) No. 9626 P. 1/1,002 r STATE OF IOWA ;`` ,.. '4, .-.� foi,A `.: Criminal History Record Check = .,-, .= e `1�' --.. .:_�T. Request Form rr,,.,, DCI Account Number: (if oppllmble) To: Iowa D1viston of Crlminal Investigation From: ',kik . e 4 tti Support Operation®Bureau,1"Floor 215 E,7d'Street g-.�h n C�z Des Moines,Iowa 50319 (516)725.6066 (6119)725.6090 Fax Phone: kq.',..- 0-abK1 Fax, .(k`52-5A-9.3vAlp I am requesting an Iowa Criminal I3igtorz.Record Check on: Last Name(mandatory) First Namezendatoro Middle Name(rcoammended) `rl (NJ `Z)-eR.IV 121Z6H` L t `1'Cfi. Date of Birth(mandatory) Gender(mandaiory) _ Social Security NumbeisaaQpuntmaoo) 3\t l\sa DMale I�Female 5rl 1-LA Waiver ln orinadon: Without a elgoad waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 692,2,For Complete criminal history record information,ad allowed by law,always obtain a waiver signature from the eubJect of the request. Waiver Release:thereby give pemilsolon for the ebovo reguauting afflefet tot oaduot en Iowa criminal history record chuck with the Division of Criminal fAvcnt{getfon(DCI), Any ortmine Iaery dela cocu;cminy 1710 theta malnlalnai by the DC!may be released as allow:d by low, Waiver Signaler-: lk,, , 7.114.4. Av. _0.-. ...n.a lona Criminal History Record Check Remits (DCl,,,00nly) As of 9 /3//tt , a search of the provided name and date of birth revealed: r c-:, ren i 0 No Iowa Criminal History Record found with DCI (—)-: — a r) C' 1. ❑ Iowa Criminal History Record attached,DCI i _ = '; .., N --..+ DCI initials =. •:t , • Received Time Sep. 10. 2014 1 : 21PM No. 9879 ' Page l of 2 .44 ' -- VVWW.iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN —.— __.__._.- _ .__,:�. 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: 9/10/2014 DL/ID #: 553XX8770 (IA) Customer#: 1877535 Name: Haman, Bernadette Class: D ID Status: VAL Leigh Desiree Address: 1001 CROSS PARK AVE Audit#: 8431921 DL Status: VAL APT B Issue Date: 09/10/2014 CDL Status: None City/State: IOWA CITY, IA Expiration 03/11/2015 CDL Cert None 522404482 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 1001 CROSS PARK AVE Restrictions: Corrective Lenses Restriction None ^." APT B Date of Birth: 3/11/1982 Supplement: Mailing City/State: IOWA CITY, IA Sex: F T_-c- ,,.-fl 522404482 "; r"'t � r'—;; "t7 _. ---1 C) CI -D 3"l History Information .4- rri 7 :� CD:J- ��` N) ..�. Convictions '. Citation Date Conviction Date ACO Explanation County JUR 10/17/2007 12/19/2007 820 Driving While Suspended, Denied, Cancelled, Revoked Washington IA 02/08/2011 03/10/2011 820 Driving While Suspended, Denied, Cancelled, Revoked Johnson IA 12/09/2011 01/13/2012 B20 Driving While Suspended, Denied, Cancelled, Revoked Johnson IA Sanctions a yPe Effective End ACD Explanation Occurrence JUR JUR Suspended 01/07/2011 08/01/2012 WOO Unpaid College Loans IA IA Suspended 06/29/2011 02/12/2014 D53 Non-Payment of Iowa Fine IA IA Barred 02/25/2012 02/23/2014 WO1 Habitual Offender IA IA Suspended 05/10/2012 02/12/2014 D53 Non-Payment of Iowa Fine IA IA Name: Haman, Bernadette Leigh Desiree DL/ID: 553XX8770 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: _'_`aENICIf AN,. 9/10/2014 Page 2 of 2 9/10/2014 { elee Office of Driver Services Iowa Department of Transportation Name: Haman, Bernadette Leigh Desiree DL/ID: 553XX8770 ry •;7.C) f y) • --3 C") cl r� rn L o I N 9/10/2014