HomeMy WebLinkAbout18-0671
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-SO40
(319) 356-5497 FAX
Last
1. Name (REQUIRED) _
2. Address (REQUIRED) L
IDENTIFICATION NO. I o-1
(Office Use Only)
APPLICATION FOR TAXICABi IVfOTDRtZED PEDICAB VEHICLE DRIVER
(Police Department reviewt JULi made between 8 a.m. to 3 p.m., Monday— Friday)
T61
T61AM 11: 16
3. Contact Information (REQUIRED) Email:
4a. Driver's License expiration date (REQUIRED)
IOVYA CITY IOtI;;
First Middle
s/ii � cym > ��YIi Cell Phone
written communieation sent via email)
b. Taxicab Business Name (REQUIRED) zrZ n
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? Alo
Tvce of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years Ah
Tie of offenseWhere When
9. Have yott ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
04/2018
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
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).
I heret� certify that I have i sued to me by the Iowa De art ni of Transportatio a alid Drivers license number
�13� C %�% issued on / 3 /S expiring on ' C ()Q0. I understand that if I
falsely answer any questions in this application, that this ap licati n may be denied. I agr a 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 a plication, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of thevi 'on of T', le 5 C apter 2, of the City Code. (Needs to be sign i front of a Notary Public)
Signature of Applicant Date
4****}'#****f*'f}1f1M11f f**f***}y}}111f1111H**Y*****1M11111H1111fi#,t}***y*}*111111*Hf**1e*****11}1!111*f*}**}*111111***}*}}f 11111**}*k}N}f 111
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 0,M on this 6 day of
Public in and fbr the -State of Iowa
I have reviewed this application, DCI report, and the State certified driving record of this applicanV.Kd have deted that
there is no information which would indicate that the issuance would be detrimental to the safety f�lth�welf�f resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code). I I a
Expiration date of Driver's license
� r,
7-tk-Ili!
Signature o olice�IC I
ief or designee Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Siig of City Clerk br designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
1 will
Date
Gert✓rAXIDRIA ADGWPL9201aa"nde .DOC 04/2018
aJo1.Iljl)18512,05PM�CabDiv of Criminal Investigation No. 6615 P. 2/3
OW03193382708 P.0021002
STATE OF IOWA
Criminal History Record Check , .K
'.bequest Dorm �
h*: DCI Account Number: 9967.)
�" (ICepplieabla)
To: Iowa Divisloa of Criminal lhvestigailon
Support Operations Bureau, 1" i?loor Erol.- k011ow Cab of Iowa City
215 9.7" Street F,O, Box 428
Des Moines, Iowa 50319 5; Iowa City, IA. 52244
(515)725.6066
(515)125-6080 Fax (319) 338-9777
Phone:
Fax, (319) 33 P-1302
�I.
I am re uostin an Iowa Criminal T•Iisto 7tecord Cheek on:
Last Name (nwndl c First Name mnditory) Mi die Name (eoommended)
J�
bate of Birth mandatory) ,Gender ) (mandato y -Social -Security iYttmb
er ryp(Moomromdod)
Waiver 1 formalion: without a signed waiver from the subject of the request a oomplyte rrlmival history record way not
be releasable, per Code of Iowa, Chapter 642,2. For complete criminal history. record information, as allowed by law, always
obtain a waiver sl nature from the sub'eet V
10f the re oast,
Waiver -Release: I hereby give permis ' n forth "dbovo requooting otli lel to eendau le Yvwa criminal Lloryreeerd chcok wirh the Dlvblon of Criminal
Irtvcsugation 0000. Any criminL history a concern! g mo the 1 In t1 by tho bel may be «leued a 'ailowcd by law.
Waiver Signature:
...,.. » vA Al1111141 1.tl,7etir acrom .t•,1lecK Kesuit9
mcr sien,y)
_
As of search of the provided name and date of birth reveals
di
tL{_
1a No Iowa Criminal History Record found with DCT
xy
Co
Iowa Criminal Histoxy record attached,•DCI #frrt
a.
M
DCT initials 1
M
DCS -77 (08/25/10)
Received Time Jul -11. 2018 2:59PM'No,1947
JIGWADOT4
SMARTER I SIMPLER I CUSTOMER DRIVENWWw.IOWadogOU
DrNaf B Idwiti Eeation Sai vicas
PO Box OM I Des minas. IA 503110204
Phone: 515-244-9124 1 Fat: 5152337847
Certified Abstract of Driving Record
Inquiry Date:
7/11/2018
DL/ID #:
235CC8779(IA)
Customer #:
1572820
Name:
Noun, Pamela Joy
Class:
A
ID Status:
None
Address:
106 N BAKER ST
Audit #:
9572924
DL Status:
VAL
Issue Date:
11/13/2015
CDL Status:
VAL
City/State:
KEOTA, IA
Expiration Date:
10/09/2020
CDL Cert Status:
Excepted Intrastate
522489705
Endorsements:
Tank
CDL Med Status:
None
Mailing Address:
PO BOX 45
Restrictions:
CDL Intrastate Only
Restriction
None
Supplement:
Date of Birth:
10/09/1964
Mailing
KEOTA, IA
Sex:
F
City/State:
522460045
History Information
CLEAR DRIVING RECORD
Name: Noun, Pamela Joy DL/ID: 235CC8779
Pursuant to Iowa Code 4321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa Department of Transportation,
do hereby certify that I am the custodian of the records held by Driver & Identification 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:
Name: Noun, Pamela Joy DL/ID: 235CC8779
7/11/2018
ACAS
Driver & Identification Services
Iowa Department of Transporation