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Home My WebLink About18-103f 1 r 1 714 III CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-SO40 (3 19) 356-5497 FAX Last 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. - (Office Use On APPLICATION FOR TAXICAB / MOTORIZED PEDICAS VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) Failure to complete the "required" information will result in denial of the application First Middle s. contact Information (REQUIRED) Email: SIC l0! Ot Zoe �Q Wtnt i CmYln Cell Phone: 31q-3�f� �ZZI� (Ah written oommunica i sent via email) 4a. Driver's License expiration date (REQUIRED) ZO b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: k c v - t) I -V V, �-14 ((6t,J CCS b 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Iliy Type of offense Where When What happened to the charge? (Circle one) 3 - Convicted Dismissed Deferred Suspended Plead Guilty u/ilty- ghera j v i 7. Have you been arrested/ charged with any traffic offenses in the last five years? /I / -`'+ Type of offense Where When w 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? _ Type of offense Where When N0 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) �Jo FOR 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 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Drivers license number 432 yy 5_7t,_ Je 7 issued on �� -1- - „o expiring on p -Z3 -Zo 1 understand that if 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, ChP� 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant / < Date /0 -I Z --t -b- mame�»•++s�r�y-�ray,»im»»:m»�»��t�»x:�»�:�m�mi»»,ret»+»��»��mm»W�:r ��»rw�mt»»m»»»»�»��m»tee»�»»:mw STATE OF IOWA ) COUNTY OF JOHNSON ) h ub cribed and sworn o before me by on this1a r' ` day of CHRISTINE OLNEY Notary Public in and for heState of Iowa Z • ' • • My Commi W *++Rea+waem��e+fr�Ret+xee»*we+»+.eewR�m»r`t��ewekr�,R»v.»�,�„:nvk�,eemt 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 Driver:' nse 97 Sig a of Police Chief or designee u1-z3-z�� 10 -17 --le N a ) AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB-TNIOW ITYEQR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. . _ I a Y "Ci %O %116 �gnat� _ DatO; _ J Office Use Only Approved application DCI report State certified driving record Website update Clerk fMIDRNMDGEAPPL0201 Bam ded.DDC 04/2018 Dlv of Criminal Invesflgation N4988 Px1:�19Peab a>>31933B027002�iSep2120183 . STATE OF IOWA Criminal History Record Check Request Form l To: Iowa Division OrCNtnlpal Inv.esflgation Support Operations Bureau, I" Floor 215 E, 7'" Street Des Moines, Iowa 50319 (515) 72S.6066 (515) 725-6080 Fax I am requesting an Iowa Crimine.l R;srnruleer A Ph.> t, ,.h. DCI Account Number: _ 9967-F (if aaPt1eabk) From: Yellow Cab of Iowa CltX P.O, Box 428 Iowa City, IFS. 52244 (319) 338-9777 Phone - Fax: (3X9)339-7302 [Last Name I Virst Name ("'damm NArne (r000mmonded) ' Iowa riminal Risco . Record Check Results iPotF, r, 66 av,v►si � a \ � , a scazch of the provided name and date of With revealed:':. Date of Birth mandato CxeQ(lel mnodato Social-Seeuri Numb recommended �'Z.'��`�9 ❑Male �etnaie 1 �$'i.�oco-`15! � WaNer Infor7natiOn: Without a signed waiver from the subject of the request, m a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For om criminal history -record in#ormetlon, ezt allowed by law, always obtain a waiver signature from the suh ectofthe re uest ii, ' WaNer Release:I hereby give permission for the sbovc tcgUating official to conduct an Iowa criminal history record checkwith the oivision of Criminal lnvestlgaHon (DCI). Any criminal history data.eonceming a that is maintained by the DCI may be Named as allowed by law. Waiver 1 Signature; DC07 (08/25/10) Received Time Sep. 19, 2018 12:44PM No,4492 Iowa riminal Risco . Record Check Results tncreaeonly) As of � a \ � , a scazch of the provided name and date of With revealed:':. No Iowa Criminal Histoiy Retard found witla DCI t ..h 0 Iowa Criminal History Record attached, DCI 9 DCI nitiale..._ C) DC07 (08/25/10) Received Time Sep. 19, 2018 12:44PM No,4492 Seo•21.2018 3:19PM Div of Criminal Investigation No.4988 P. 2 DISCLAIMER This response can only Include public criminal history data. Under Iowa law, 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 request 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: h_ttp://www.iowasexoffender.com/. However, even though some information Is available on this site, the actual records forjuveniles 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 filed pursuant to Iowa Code section 232.147(18). �1�4.. DO wrvhrv,iowada. av SMARTER I SIMPLER I CUSTOMER DRWEIt Driver & identification Servic" PO 6cx'M 1 Des tines. IA 533C61r2fA Phone 515-244-91241 Fax 515" 239-1837 Certified Abstract of Driving Record Inquiry Date: 10/12/2018 DL/ID #: 432YY5707(IA) Customer #: 3875157 Name: Prymek, Donna Class: D ID Status: None Marie Address: 1129 KIRKWOOD CT Audit #: 1373342 DL Status: VAL Issue Date: 10/18/2016 CDL Status: None City/ State: IOWA CITY, IA Expiration Date: 09/23/2020 CDL Cert Status: None 522405772 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: 1129 KIRKWOOD CT Restrictions: Corrective Lenses Restriction O None Supplement: CD O Date of Birth: 09/23/1979 '"' n Mailing IOWA CITY, IA Sex: F City/ State: 522405772 n History Information rn CLEAR DRIVING RECORD w _1 Name: Prymek, Donna Marie DL/ID: 432YY5707 i� 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 sald 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: /vµ' vS �1S'o ,�, 11 Name: Prymek, Donna Marie DL/ID: 432YY5707 10/12/2018 C Driver & Identification Services Iowa Department of Transporation