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HomeMy WebLinkAbout18-108CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX IDENTIFICATION NO. (Office Use Only) APPLICATION O114AXU! MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) 4 Failure to comole 1)ri' re m7red information will result in denial of the aoalication Last ' 1. Name (REQUIRED) 1 First Middle 2. Address (REQUIRED) 7d t 0 » z(////,6__ - !f 0-l" 3. Contact Information (REQUIRED) Email:Phone:. (All written communicatioLaent viae ail) 4a. Driver's License expiration date (REQUIRED) -1,�=- 0 1 - a- D I Y b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers:S 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) 0 Convict Dismissed Deferred Suspended qsad Gui Other Igvs�u been arestoed / c arged ith any traffic offenses in the last five years? T of o se 'Ru_S �%4%r S t7y1 CnJi (Yl f�V�he (P C93 -0S-amts Convicted Dismissed Deferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? tt�1� 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) Kt:UUIKED 04/2018 -a-S Al-;� ) I ,-f)IA APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND ST 14 sCERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLIOS 10HIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (four available upon request). 2�1" 2; by certify that I have issued to me by the Iowa Del2artmentf Transportation a valid Driver's license number issued on f� _6Z—/5_— OOiring on ! 1- 1- / sy I understand that if I falsely answer any questions in this application, that this application may be denied. 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—N STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by LOic9tLa_iP-f yCge j? on this Z[ day of Orva"tir '70125 VaND`r 71 0S Notary Public i J and for to of Iowa 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 Sigpalure 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. or designee Office Use Only Approved application DCI report State certified driving record Website update =I" -t Date aerPJrw 1MFV8ADGe PLe201eefded.DOC 04/2018 C4'GWADOT www.io,►„ edoc ov SMARTER I SIMPLER I CUSTOMER DRIVEN 9 Dtlwr d lawar4adoel aatvlaas r' r PO Boz 92041 Des Niobtes. to 608088204 Phone: 516244-91241 FOR 613388{1887 Certified Abstract of Driving Record t - Inquiry Date: 11/21/2018 DL/ID 7f: 787AK0765. (IA) CDL Permit Class: None Customer #: 5608287 Class: C CDL Permit Issue Date: None Name: Phllogene, Wldmaier Audit ft: 1768818 CDL Permit Expiration None Date: Address: 927 BOSTON WAY APT 12 Issue Date: 04/25/2017 CDL Permit None Endorsements: Expiration Date: 12/01/2019 CDL Permit Restrictions: None City/State: CORALVILLE, IA 522413159 Endorsements: NONE ID Status: VAL Mailing Address: 927 BOSTON WAY APT 12 Restrictions: SR Required DL Status: VAL Restriction None CDL Status: None Mailing CORALVILLE, IA 522413159 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 12/1/1983 CDL Cert Status: Non -Excepted Interstate Sex: M CDL Med Status: Certified CDL Medical Examiner's Certificate Certificate Specifics I Explanations Medical Examiner Firs[ Name Ryan Medical Examiner Middle Name Matthew Medical Examiner las[ Name Dowden Medical Examiner License Number 35434 Medical Examiner National Registry Number 19565950912 _ Medical Examiner Junsdiction _ - IA Medical Examiner Phone _ _ (319) 369-7211 Medical Examiner Type Medical Doctor Medical Certificate Issued Dale _ _ _ _ _ _ 09/01/2015 Medical Certificate Expiration Date _ _ _ _ _ _ _ _ _ 09/01/2017 Date Added to CDLIS Driving Record 03/12/2016 History Information Convictions :itation Date Conviction Date ACD Explanation JUR County 104/04/2014. 851 _ i No Drivel's License IIA Muscatine X3/11/2014 _ .. _ 04/04/2014 1 864 !No insurance Card IA _ iMuscatine _ - Speed _ IA John son s -- 1 2/26/2016 05/26/2016 �M75 Passing School Bus 1 IA Johnson Sanctions Type Effective End ACD Explanation JUR Occurrence JUR ftwmw-y 106/30/2016 1107/29/2016 '.M75 'Serious Violation IIA !IA Name: Phllogene, Wldmaier DL/ID: 787AK0765 (IA) Pursuant to Iowa Code 4321.10, I, Darcy Doty, 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 1 have been authorized by the Director of the Iowa Department of Transportation to so certify. In witness whereof, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: ,MENS o, r9a De 11/21/2018 UL Alito— Driver & Identification Services Nov. 16. 2018 9:24AM DCI IOWA 11412/2018 0920 YeOow Cab No. 1485 P. 1 ffA11xi199992708 P.0021002 STATE OF IOWA Criminal History Record Check Request Norm if Tot Iowa Division of Criminal Investfifation Support Operations Bureau, I" Floor 215 E. 7' Street Des Moines, Iowa 50319 (515) 723.6066. - (515) 725-6080 Fax I^ 1 am reauestina an Iowa Criminal History Recotd Check on: ILED DCI Account Number: 9967-P (if applicable) From: Yellow Cab of Iowa Ciro Y.O. Box 428 Iowa City, TA_ 52244 (319) 338-9777 Phone,• Fax: (319) 339-7302 LkAt Name tmandaro First Namendao Middle Nome neommendee Date of Birth tmmdawry) Grander maade 'Sodal-Sec Numb (—ommrn !� - ©i-11 g-3 G�Male ❑kemala 3a 9- 0� 73 . . Waiver Information: Without a signed waiver from the ailbieer of the rggpaar, a complete grimlnal history record may not be releasable, per Code of-Iowe, Chapter 6$.2.2. Icor cam plote criminal history-xecoro In('ormi0on, ai allowed by law, always obtain a waiver signature from the sub'ecVbf the request Waiver Release: t hereby give pcnnW194 for the above mqueaing official to weduot an Iowa criminal historyreoord eherk with die Division of Criminal lovaaipMon(Deer). Any odminal history date boncendgi= Net b maintained by the pal may be felsand as ano,vcd by law. Waiver Signature: Iowa Crin"al History Record Check Results '. 0pq eee,gdly) Ano l!'!� e search'. of the provided name and date of birth revealed-,- 2, evealed t r; y No Iowa Criminal Histoo Record found with DCI (7-). Z x ❑ Iowa Criminal. Iliatory Reeord atta bed, DCI it DCI: tials DCI -77 (08/25/10) Received Time Nov, 12, 2018 '9;27AM No.0732 Nov.16.2018 9:24AM DCI IOWA L DISCLAIMER No. 1485 P. 2 This response can only Include public ,tirtminal history data. Under Iowa law, most Juvenile records are confidential. Confldentlailuvenile court records, if any, cannot be Included In this response.- A signed release authorization Is not auff/clent to obtain this Information from the Divlslon'of Criminal investigation, In order to request Mg. release of confldentlalJuven/le records; If. any, an application must be filed pursuant to Iowa Code ssctlon 232,147(18), Additionally, criminal history date concerning convictions for certaIn Juventle sox offenses. can be found on the Iowa Sex 0ffenderReglstry: (t 'A www lowasexoff r.c However, even though some Informaticn Is avalleble on this site, the actual recor, s'forJuv,rlles piny still Aa confidential and any cpnfidant/al Juvenlie records cannot be provided with'fhls record, In order to request the release of con fidenfial Juyenlle.records, If any, an appi►patlon must be filed pursuant to Iowa Code section 232,147(18),