HomeMy WebLinkAbout14-058 Authorization Number / q 5g
4
1 (Office Use Only)
= SIM;612b10
"4 NS all II gifir
APPLICATION FOR TAXI 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 !�T ei t Vl e- ��1 G{Y I` f L(,1 L G- 1.-O I 7�
2. Mailing Address /3 S n it/1u c E 7 —��>{,� e j i/ :j
3. Telephone: Home (S i'1) 93 6`-1O gq Other: r
4. Prior experience in transportation of passengers: C1,1:19 rel lri'V E'v & 1.ff-tocc C 1 y /?(r c' 7d octroe4
IMO 0.4 0C "f-tA)C) /�! 7',3 `d 14.v!�P
SY s Lt1,t /,'u41`7L � eJ (-ate iocv,ker /q8' — �� )�
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /v�)
Type of offense Where When
6. Have you be n 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? AIC)
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? fV
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)
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)
clerWtaxidrivbadg 03/2013
I hereby certify that have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
. 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 ti eswith all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) 6,4Signature of ApplicanDate i61 1 L�
STATE OF IOWA
COUNTY OF JOHNSON ) rr
Subscribed and sworn to before me by Hc, lcvk , 'Ivl . Lt.A6.(v t- . On this `-l- it day of
wENDY S.MAYER Notary Public in a for the State of wa
` Oe mlnamon Numoer 128428
My Commission 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).
2.r0/
Signaturf Police 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.
�/7
Signat.xre 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/taxidrivbadgeapp2010.doc 03/2013
v
SMARTER I SIMPLER 1 CUSTOMER DRIVEN tJUWW.tOWHdOt.._ _
Office of Driver Services
PO Box 9204 I Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-1121 Fax:515-239-1837
'www.iowadot.gov
Certified Abstract of Driving Record
Inquiry Date: 3/4/2014 DL/ID#: 636MM7805 (IA) Customer#: 1621790
Name: Lubaroff, Helene Marie Class: D ID Status: None
Address: 1514 SPRUCE ST Audit#: 7195672 DL Status: VAL
Issue Date: 08/01/2013 CDL Status: None
City/State: IOWA CITY, IA 522406030 Expiration Date: 02/03/2019 CDL Cert Status: None
Endorsements: 3 CDL Med Status: None
Mailing Address: 1514 SPRUCE ST Restrictions: NONE Restriction None
Date of Birth: 2/3/1966 Supplement:
Mailing City/State: IOWA CITY,IA 522406030 Sex: F
History Information
CLEAR DRIVING RECORD
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
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:
a11Clf 4"
4' .. ..' 4, 3/4/2014
/47 IOWA
i a elect:0.0k
fp. O. T.143.7
,I+'dek
'4% fit,' Iowa Department of Driver
rtmeServices
of ITnansportation
Name: Lubaroff, Helene Marie DL/ID: 636MM7805
oz.Feb. 21. 2014.3 2:40PM Div of Criminal investigation DCI 'JO. 3541 P.LI/4,
•
STATE OF IOWA -a 1c`',,,;
Criminal History Record Check
Request Form
,t,mA
DCI Account Number 93f 3-R-
^f'' (btygleetial
To: Ion Division of Criminal toveatigation m: I e Proto�+, f jf 1
9apport Openlions Buren,t^Floor
215E.7'bStreet II4 54-tetr1 Or.
(51b1 22334OM 50319 -
fith CsAl
e /l� S ,.:Vi n
(515)7256030 Fax • /
•
Phone; :1314) 33"My'
Fan:.. 31'1) .Sl-$a99
I sin requesting an_Iowa Criminal Histoiy Record Check oni -
Last Name(mu 4sw y) cheat Name(mwan'y) Middle Name(rocomneaed)
C,wbakRale.M. e - Mane
Date of Birth(eo,owpry) / Gender(me,wmryl Social Security Number t:emn,
oomeaa
0a/O3 II 7614' []Male (4Femele if 946—g &39
Waiver Ltformadon:Without a signed waiver from the subject of the request,a complete criminal history record may not
be releasable.per Code of Aon,Chapter 692.2,For k4ll&ate crlmmd Hilary record Informatlou.u'Dowed bylaw,always
ah ana a waiver alyauure Wan the subject of the ream.
ii'aiwrReleaseiharbyeve pamlukntot ChB above .. zomcidmendudUIOWAtimbal h4towmoi Ora whhdoDbilitoofCAmbW
ImaaptbO(Dco.kw aimhrl Wary don •• •• roeituoe/d1g' 1l be roktledu elo q'bw.
• Waiver SignalWB:•• •I f . • 1- j�—` - • -'—--
Iowa Cr minas Iltistory Recoorrd Check Results �ae; aA 'r ";
M of !JAI 1 L ,a starch oftho provided name and date of birth revealed; r 1 c•: _ (..i,
id) '' W :r':n
1,e No lowa Criminal Hism Record found with DCI c);:1:}. :; '
tY T' o
25 a: y
Iowa CFI:tllnal History Record attached,DCI il_ 2-.1:--- w
DCI Initials hh
DCI-77(08/25/10)
•
eceived Time Feb. 19. 2014 1: 10PM No. 9872