HomeMy WebLinkAbout18-094IDENTIFICATION NO. 1`ff7--77 1. Z_
% 1 (Office Use Only)
APPLICATION FURLEADMOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday)
CITY OF IOWA CITY�� � �� * 1
410 East Washington Street Failure to complePate to ation will result in denial of the application
Iowa City, Iowa 52240-1326 CITY CLERK
(3 19) 356-5040 IOWA CITY. IOWA
(3 19) 356-5497 FAX First Middle
LastA �l_
1. Name (REQUIRED) P r
2. Address (REQUIRED) ZrK LP -If Z
3. Contact Information (REQUIRED) Email (I ytn 1 Cell Phone: -J CI- Z�/
(All written communicat n sent via email)
4a. Drivers License expiration date (REQUIRED) 40 1 AP -1-1477
b. Taxicab Business Name (REQUIRED) U -'e I1 nxLrf h
5. Prior experience in transportation of passengers: 2 E IA int r I VVI V0E2
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A &2
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?
Type of offense ((Where When
f' �^
nd' ""��Ur\ IbI��IIJ
What happened to the charge? (Circle one)
Cots" 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?
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)
04/2018
Y
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPO �I}D =CER IIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION �p
You must apply for an individual Department of Criminal Investigatiovgpp (r Milablq ypon request).
T.
CITY CLERK
IOWA CITY.IOVJA
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
L}p�{ (� y:Z -� issued on 4/ (o /lK expiring on I understand that if I
falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Till 5, Chapter 2, of the Ci Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant oY Date /3/ IL
STATE OF IOWA )
COUNTY OF JOHNSON )
S bscribed and sworn to before me byyyo ,ma on this 3kst' day of
mat 8
Notary ublic in and fo the State of Iowa 3�2°
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of D 's 4inse—//Z/7�L�
Signature olice Chief 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.
of City Clerk
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
GaM MIMRAM GEAPPL9P lMnwnded DOC 04Y2018
".1.11, [V IV 7--rVMir uiv or unminai Investigation No. 0465 P. 1/4
08/21/2018 7;19 AM FAX 319439702 00009/0009
FILED
STATE OF IOWA gg �" ►,
Crimil181 History Record ChecJ018 AUG 31 -�
Request Form CITY CL
10 WA CITY, .V""
To: Iowa Divirloo of Criminal Invadgption
Support opontions Bureau, I- Fluor
215 l;, 7' Strott
Des Moloea, Iowa 50319
(515) 729.6066
(515)725.6080 Pax
jq
K'olverbonrrafion: Lthou
be reltaspble, per Cod* of Iowa,
DCI Account Number; _9967-F
(depplicablo)
From: Yollow Cab of Iowa Ci
P.O. Box 428
Iowa Clty, IA, 52244
Phone: (319) 338-9777
Mki; (319)339-7302
I❑Male Weinale I 7 0 -3 '
a signed wnwor from the VubJect of the rryue34 a eomptote criminal hhlory record may not
:Iw1 jb c t afth For quest. `o criminal history record information, as allowed by taw, always
o sub act ofthe request.
Wt7ly
"009c'r Wl). B; I h cby Minalgive Iwnnuw m ra the.hoveNyuahne a0ielm m eonauq nn levee criminal himoryrecord chc* viler Inc DivlSloa u(Comiaol
l""m'aibyn (�A• My crim'owl hbtory dan concemi10 Ihur1 nloinudncd by rho DCI may be rolon�.l as nllowya bylaw.
Walyer
As of -18 s search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Rccord atttccheedd, DCI #
DCI initials "
DCI -77 (M25/10)
rv) ;,: ,
(DCI *se only.(
L,'o-.1
>
o�
CJ10WA00T FILED
SMARTER 1 SIMPIER I CUSTOMER DRIVEN 201QU1*9L/4q0V
auon 3Hmwos
PO So� r IA %3V> Mi
S2Q9-1897
Certified Abstract of Driving Record
Inquiry Date:
8/20/2018
DL/ID #:
Name:
Roate, Amelia Kay
Class:
Address;
9 PARKSIDE
Audit #:
04/06/2018
ESTATES RD
None
12/12/2024
CDL Cert Status:
Issue Date:
City/State:
WASHINGTON, IA
Expiration Date:
Corrective Lenses
523532954
Medical Report
Supplement:
Endorsements:
Mailing Address:
9 PARKSIDE
Restrictions:
F
ESTATES RD
Date of Birth:
Mailing
WASHINGTON, IA
Sex:
City/State:
523532954
Convictions
409AF7422 (IA)
Customer #:
5365333
C
ID Status:
None
2703273
DL Status:
VAL
04/06/2018
CDL Status:
None
12/12/2024
CDL Cert Status:
None
NONE
CDL Med Status:
None
Corrective Lenses
Restriction
Medical Report
Supplement:
required 4/2019
12/12/1992
Operating a
F
History Information
Citation Date
Conviction Date
ACD
Explanation
County
]UR
110/17/2015
111/18/2015
S92
I Seed
Marion
IA
Sanctions
Type
Effective
End
ACD
Explanation
Occurrence
JUR
JUR
Suspended
01/02/2018
04/05/2018
W20
Incapable of
IA
IA
Operating a
Motor Vehicle
Safely
Name: Roate, Amelia Kay DL/ID: 409AF7422
Pursuant to Iowa Code §321.10, 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: Roate, Amelia Kay DL/ID: 409AF7422
8/20/2018
AFILE
oil OT PM 3:21 0
Driver & Identificatio""e£LERK
Iowa Department t0ftTraf, 10 WA