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Home My WebLink About18-098el � l 1 CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX IDENTIFICATION NO. (Office Use Only) q , r-" APPLICATION FOR TAXIC" � i512I ED PEDICAB VEHICLE DRIVER (Police Department review must be made between JQ a.m. to 3 p.m., Monday - Friday) ?ale SFP 28 b I CITY ULttttI lov-,`N CITY, 1C arrs First Middle Last rr 1. Name(REQUIRED) c "d't✓IoCZ.610w5l,t dilacA 2. Address (REQUIRED) �ilLn "i r,"I -S-f- Ott; I C :L, Szzlp 3. Contact Information (REQUIRED) Email: r2 mnoGzalowik:42 coaCell Phone: S11-30--6363' (Alf written communication se via email) 4a. Driver's License expiration date (REQUIRED) (2 7- IL 7 Z -,b 7� b. Taxicab Business Name (REQUIRED) ye I how C..% 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? Yc,--, Type of offense Where When 'LIL �t�o�C It�aSy1'c�a C�un�r johuf Sos>acnde.J I?es5css o�1 nF Can 5"h ahASna cdd�v 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? o Type of offense Where When NI /k 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? /V Type of offense Where When k) 4 9. Have you ever applied to. be an Iowa City taxi driver using a different name? If yes, please provide the name(s) k1A (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT -4111D STAB CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATIONOQ41Q� 4iHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available upon request). 2016 SEP 23 AM 10: 58 CITY CLERK j0'VlA CIT Y.I071''A I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number �b3 _ Z y 9 9 7 issued on expiring on l Z7 1? -q. 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant-� Date�c/ /L STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me byRi'_&Og1 day of S e_ a -C wENDY S and for the Sta* of 1 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 er, cense 0 Z - Z 7 - Zo `/ Signal of Police 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. Office Use Only Approved application DCI report State certified driving record Website update q-)Lk-/� Date Gary✓rn M[VI AOG�9MIM.*rKW CM 04/2018 C410WA130T SMARTER ISIhlLER I CUSTOMER DRIVEN WWWAOWadot- SEP c3 A i 10:53 Dmar8 WNt�igNpn IiNv pc3 Ebx cart. i Das Maw. IA s000s i �' CL_ r �; i Prgoe S 15-2U-91241 Faz 31b29q ft#r; r i T CLEAR DRIVING RECORD Name: Ciemnoczolowski, Michael James DL/ID: 803ZZ4997 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: N, IT Or 9/17/2018 F a_ /y C Driver & Identification Services Iowa Department of Transporation Name: Ciemnoczolowski, Michael James DL/ID: 803ZZ4997 vi Certified Abstract of Driving Record Inquiry Date: 9/17/2018 DL/ID #: 803ZZ4997(IA) Customer #: 3489561 Name: Ciemnoczolowski, Michael James Class: C ID Status: None Address: 816 S GILBERT ST STE 1 Audit #: 2756199 DL Status: VAL Issue Date: 04/26/2018 CDL Status: None City/State: IOWA CIN, IA 522401756 Expiration Date: 02/27/2024 CDL Cert Status: None Endorsements: NONE CDL Med Status: None Mailing Address: 816 S GILBERT ST Restrictions: NONE Restriction None STE 1 Supplement: Date of Birth: 02/27/1981 Mailing IOWA CIN, IA Sex: M Ctty/State: 522401756 History Information CLEAR DRIVING RECORD Name: Ciemnoczolowski, Michael James DL/ID: 803ZZ4997 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: N, IT Or 9/17/2018 F a_ /y C Driver & Identification Services Iowa Department of Transporation Name: Ciemnoczolowski, Michael James DL/ID: 803ZZ4997 vi Sep. 20, 2018 9:04AM Div of Criminal Investigation No. 4621 P. 4/7 09/17/2018 1322 Yellow Cab fAX)319 338 2708 P.0021003 FILED S'TATT 01'0WAYU'18 SEP 28 AMID -5 GA -HU. a)ryRevord'CheelkY CLERK Request Forint i 0 VSA CITY, MVI f �. T6*' JON"ltYri3l4iioitSimihallayesifgalton ]":Floor 215 s -70 Street: DesXoluks icr.➢n 511319' SS�'1x5:6t;6b . C1t3j �3�.6i>�D'Psx . I nu—G 'DUAacountNtmiber; __,_9967-F tYfnppllcnbtol Frarn: _X> hoar Cab oflatga.G�it9 . 'k:A.B'ox 428• IotvB 4C4, TA. 5 • 4 (31Xj 338-9177 P4onfA pax: (319) S39-I30� iVa1m - ^MrOI lanie:W4610 1'.: 1Xdrddli xlemt era a�a1. //l.asf Dale iwe +Gonidet i ;_::.Sos lSeati ' . N1 big ,o,�eea 0L7,/t/l98 / Mete �Feutgim y�$-�z - �g y5/ ?lVe lnj�iiltftfion: 9Vi 1i6 gt:4alPA 51`AW'e.*gi t4tibj :flf t8e:regaea4'� eatai ilete cj*`i�l history racoad. W*y:uat taerdeara8le,pet.Codeof.IowaaGHapter651Stx'Ror'rom 1 tris iati-History,recerdfittormatlor gvtftao4dby]Rw,alwap o talo sxxloerd •atixe�trom.tHes�t.6 eel atfli6r: 8ta'C : • . Wtliyrr ReYearsec Cdsrl�Xg(vO��yh�7�'"�I�Ft�N�fipoab0ve�gquea[iagu�[c5ai meCo9'Xl undoWs'?i�11yi11.�1jc9dJI000}'QJi110o,R`WhAthe DiroisiooulCriminsl iovaRl�euop'(UC7),'�'�ry..Q�tG��if{Orrawuu011Ed'e•vry�711{1711�'.11{Ia0111tbi11G✓ityX tbC:i]Cim.9�''(�cxCy.WE��{ettbY4d:�}'iI�P't' 1PasYel~3'eyrmArli� OFY'8:: 1c3y7 ''119 " �leCi�. Sli $3' PCt om oet?) A9 ,of aO 4 a s'eazdh.o£tl�s avidgd na1uC and littto £birth revealed: 13 No lows CdMina$ 0*ry Aarord found with DCI �o.ava C>;itninai T3Sstoiy� Recordaltacltad,. bCT:� u', ` � a ' , DCtivitit}ls � �aA .t- `n`i .i3i;T�47 (Q>I/2•SZ10) Sep -20-2018 9:04AM Div of Criminal Investigation No.4621 P. 5/7 IOWA CRIMINAL H19TORY MISDEMEANOR CONVICTIONS ONLY DCI:00607427 NAME: CIEMNOCZOLOW,MICHAEL JAMES CIEMNQCZOLOWSKI,MICHAEL JAMES CIHMNOCZOLOWSKI,MIKE DOB SEX RAC NGT WGT EYE 19810227 M W 510 160 BLU ADDITIONAL IDENTIFIERS CCH RECORD "* 01 ARRESTED/TAKEN INTO CUSTODY 19991011 DCI 00607427 PAGE 1 OF 2 DATE PRINTE 2018/09/ '7.�'TI-Eu 2313 SEP 28 AH 10: 58 CInY�r I Y CLERK HAIR SKN POI"Q4u'n CI I , iO4: �`�• SDY FAR IA AGENCY: TA0920000 WASHINGTON CO SO CHARGE NO- 01 IA STATUTE IA123-46 PUBLIC INTOX TRK#: 034265901 COURT DISPOSITION AGENCY: IA092015J WASHINGTON CO DIST COURT COUNT NO- 01 IA STATUTE: IA123-46 PUBLIC INTOX CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 034265901 SENTENCE COURT COSTS PROBATION 1Y SUSPENDED 5D 02 ARRESTED/TAKEN INTO CUSTODY 20011211 AGENCY: IA0520000 JOHNSON CO 50 CHARGE NO- 01 IA STATUTE IA124-401 PCS I TRK#: 100420901 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE - SR COURT CASE ID: 06521 SRCRO60763 CHARGE CLASS: NON CONVICTION TRK#: 100420901 SENTENCE DEFERRED JUDGEMENT PROBATION lY SA EVAL725H COM SER DISCHARGED FROM DEFERRED JUDGEMENT DISP EFF DAT 19991109 19991109 19991109 DISP EFF DAT 20020215 20020215 20030113 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 OCT, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS r� Sep -20-2018 9:04AM Div of Criminal Investigation No.4621 P. 6/7 'BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMIHAb INVESTIGATION FILE® 2010 SEP 28 AM 10: 58 CITY CLERI(_, 10VIA CIT)'. I�`,:A Sep.20.2018 9:04AM Div of Criminal Investigation DISCLAIMER No. 4621 P. 7/7 This response can only include public criminal history data: 4TFde-iJo46/9ak most juvenile records are confidential, Confidential juvenile court records, if any, cannot be included In this response. A signed release authorization is not sufficient to obtain this information from the Division of Criminal Investigation. In order to 'quest the release of confidential juvenile records, if any, an application must be filed pursuant to Iowa Code section 232.147(18). Additionally, criminal history data concerning convictions for certain Juvenile sex offenses can be found on the Iowa Sex Offender Registry: httP,1Avww.iowasexoffender.com/. However, even though some information is available on this site, the actual records for juveniles may still be confidential and any confidential juvenile records cannot be provided with this record. In order to request the release of confidential juvenile records, if any, an application must be flied pursuant to Iowa Code section 232.147(18).