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Home My WebLink About14-069 Authorization Number 1 4 - (Office Use Only) Me MOB ZIT APPLICATION FOR TAXI/MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City. Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name A,)°1111 rf'G ret e S e bets"( e 2. Mailing Address Lf 10 Spy;A/ ,414-, () „t 4 S 2 3' 11 3. Telephone: Home 31 or • 72-0 -D o CJ c) Other:• 4. Prior experience in transportation of passengers: Alp r+ CD^I a N '1 ef(F ri%a7 c e 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? y e.) Type of offense WhereSS tt When p ��d �ekta 1 2�d 7 T.pvaa d50."4 re766 — + 51-4 d wct r/v`7nfo� Zed 7 6. Have you baen convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? NJJ Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? /V O Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? es, Type of offense Where When cseu f 4pl e4-f `th(c y ti ?- 7-I'1 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) NJ• 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) 03/2014 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number -i 3 2 - r7- ?o i L . 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 4 ,/ �/ 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. STATE OF IOWA ) COUNTY OF JOHNSON ) S bscribed and sworn to before me by &cxw\ \ `t� . On this � day of c,r . Ncitaniublic in and for the State of Iowa -7 (1k1,4 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). .111 Signature Po ice C,ie"or des gnee 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. � n 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 clerkftaxidrivbadgeapp2D14.doc 03/2014 . DoT . . 4.. n 4 rte(}j{�}- �ry\( C .:_. VVU .1oYVadols, ov SMARTER ISIMPLER I CUSTOMER DRIVEN -- ,.. .......s„ .._ - , . Office of Driver Services PO Box 92041 Des Moines, IA 50306-9204 Phone:515-244-9124 1800-532-1121 I Fax:515-239-1837 vatm.tovradot.gov Certified Abstract of Driving Record Inquiry Date: 3/11/2014 DL/ID #: 432YY3012 (IA) Customer#: 4728613 Name: Rebelskey, Adam James Class: D ID Status: VAL Address: 410 SPRING CREEK RD Audit#: 7860377 DL Status: VAL Issue Date: 03/07/2014 CDL Status: None City/State: MOUNT VERNON, IA Expiration Date: 11/11/2015 CDL Cert Status: None 523149534 Endorsements: 3 CDL Med Status: None Mailing Address: 410 SPRING CREEK RD Restrictions: NONE Restriction None Date of Birth: 11/11/1986 Supplement: Mailing City/State: MOUNT VERNON, IA Sex: M 523149534 History Information ' Convictions Citation Date Conviction Date ACD Explanation County JUR 10/04/2010 10/20/2010 B20 Driving While Suspended, Denied, Cancelled, Revoked Polk IA Sanctions Type Effective End ACD Explanation Occurrence JUR JUR Suspended09/22/2010 12/04/2012 D51 Non-Payment of Child Support IA IA Suspended 02/09/2011 02/10/2014 D53 Non-Payment of Iowa Fine IA IA Suspended ',05/10/2012 05/13/2012 D51 Non-Payment of Child Support IA IA Suspended 10/30/2012 12/04/2012 D51 Non-Payment of Child Support IA 'IA Suspended 03/05/2013 08/25/2013 D51 Non-Payment of Child Support 'IA IA Suspended y06/06/2013 08/25/2013 D51 Non-Payment of Child Support IA IA Suspended '.01/10/2014 03/05/2014 D51 _Non-Payment of Child Support IA IA Suspended 01/10/2014 03/05/2014 D51 Non-Payment of Child Support IA IA Name: Rebelskey,Adam James DL/ID: 432YY3012 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: s WOLF PI, �/ IOWA :.%, Le: , n r :tri 3/11/2014 Office of Driver Services Iowa Department of Transportation Name: Rebelskey,Adam James DL/ID: 432YY3012 Mar. 11. 2014 1 : 17PM (Div of Criminal Investigation NNo. 1624 pP. `2/3 STATE • ,r41r9� ":424t,,,,: OF IOWA =' � ei :r ! r `r- Criminal History Record Check i ;::?};;:''• l "•',L..' IIaI, Request Form \ :; ^S" ' DCI Account Number; u t --PP Of applicable) To: Iowa Division of Criminal Investigation From: _City of Iowa City ' Support Operations Bureau,1m Floor City Clerk's Office 215E.7'h Street 410 E.Washington Street Des Moines,Iowa 50319 (515)725-6066 Iowa City, IA 52240 (515)725.6080 Fax phone; 319.3864041 . Fax; 319356.5497 T am requesting an Iowa Criminal History Record Check on: • Last Name(mandarary) — First Name(mandatory) Middle Name(reeon>nrendod) loci(Pt y A-dA,n (Tames Date of Birth(andatoty) gender(mandatory) Social Security Number(recommended) /1/ 1 i/ f91r6 I.SMale ❑Fy 77 emale r' I/ - dAa / Waiver Information:Without a signed waiver from the subject of the request,a completo criminal history record may not be releasable,per Coda of Iowa,Chapter 692.2.For complete criminal history record Information,as allowed by law,always obtain a waiver signature from the subiect of the request. Waiver Release:I hereby give permission forlha above rcquesling Oficial to conduct an Iowa criminal history record chedc with the Division of Criminal Investigatlon()CI). Mya)minel history daleconeendng me Ilial Is malmained by the DCI may be released as,Ilosvdd by low. WaiverSlgnntlire:ad" . Iowa Criminal.History Record Check Results • r(DCC umnnly) • �_es - fro As of 3-i I-1`-i , a search of the provided name and date of birth revealed: <' :I. e 1 Fri(') <•; • 0 No Iowa Criminal History Record found with DCI L''? _°_' Iowa Criminal History Record attached,DCI# —I 5119 I " � ' Del initials .V,UJ Received Time—Mar. 10. -2014— 2:26PM—No. 4741 nrtn7 rnal2sn111 Mar. 11. 2014 1 : 17PM Div of Criminal Investigation No. 1624 P, 3/3 ` •I IOWA CRIMINAL HISTORY DCI 00757790 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED- 2014/03/11 DCI:00757798 NAME: REBELSKEY,ADAM JAMES DOB SEX RAC HGT HOT EYE HAIR SRN POB 19861111 M W 509 135 BLU BLN IA ADDITIONAL IDENTIFIERS CCH RECORD *** 01 ARRESTED 20050820 AGENCY: IA0060000 BENTON CO SO CHARGE NO- 01 IA STATUTE XA124-414 DRUG PARA TRIO: 074608901 COURT DISPOSITION AGENCY: IA0060151 BENTON CO DIST COURT COUNT NO- 01 IA STATUTE IA124.414 POSSESSION OP DRUG PARAPHERNALIA COURT CASE ID: 06061 SMSM003534 CHARGE CLASS: MISDEMEANOR CONVICTION TRIO: 074608902 SENTENCE DISP EFF DAT FINE $250 20051201 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON-LAW ENFORCEMENT AGENCIES BY THE DCI. IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION