HomeMy WebLinkAbout18-119Bar,
AQ
.,111 ®r��
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 3S6-5040
(319)3S6-5497 FAX
Last
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. 0�—))
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB 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
3. Contact Information (REQUIRED) Email:
4a. Driver's License expiration date (REQt
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa.
Firsstty� �Middle
/
U
11 r c ,,' 0 Q n—a 1 c' Cell Phone: ,JJ 5 6 a I -I� OQ6
written communicatio ent via email)
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Aj y
Type of offense Where When
-o -
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? s j:!' S
Tvna of nffanec Where
-�i
What happened to the charge? (Circle one)
LI
Convicted Dismissed Deferred Suspendedead Guilty --�Dther
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ALS
Tvoe 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
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 Departent of Transportation a valid Driver's license number
19 6 R 1) e g 5 � issued on Z / (y/ expiring on 3 I °I I understand that if I
falsely answer any questions in this application, that this application may be denied. I gree 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 provision of Tit, C apter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature ofApplicent Date_ / /, L
1fY'#fYflllklflYYlffYkyfllfyeNlfll1114yyflf4Hlf}ffl1111111!lyflff1111111111!llyy4!}1fllflyffyff111fl,FYff!!'kflliyf11f111flf1lf1f4lff!lyllfflfilM
STATE OF IOWA )
COUNTY OF JOHNSON
and �Usworn® C.r to before me by ,-eQ , Ll c C on this o2t day of
V t
Of
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).
iZ-cH—
Expiration date of Driver's license _ Ate+' ' ' '
Sign 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.
ignalure of City Clerk or esignee U Date '
11f1elMl1l1'Yfl,lHl111kf1flffi'N1f.111fHf1llffy.}�1 ,..' yy
Office Use Only '
Approved application
DCI report
State certified driving record
Website update
t�j
ae AXIMNS4DGEAPPL9201BameMed.DOC 04/2018
11/Dec__5_201BaLl OBAMCab DCI IOWA
STATE O -V '
Request a tt
To: Iowa Division of Criminal Investigation
Support Operations Bureau, I'i Floor
215 E. 7' Sire"
Des Moines, Iowa 50319
(515) 12-5-6066
(515) 725-6080 Fox
I am reaue,tinwan L.Y.. n.:» : at v, . _. ____...•----
fA)03193381No_ 3750 P. 1/11002
DCI Account Number; _9967-F
(If applicable)
From: 'Yellow Cab of Iowa City
P.O. Box 428
19wa City, IA. 52244
(319) 338-9777
Phone:
Fax: (319) 339-7302
T.Yalt Name mandato
uuV.Y IiYGVA YY.
tk'is et Nerve mandatory) '
1V11 (rawnme idea
AG�((
.Ij��otrr
AdI'01�(euae
1�'er
))ate! Bi t mandate
; CJonder mmaatb
Sogial seeuri Number reepomended
%Z � ! 7S" ..
Male ❑Bemale
%�'- D(� - SS3
WafYet Tt{fOrmatipn; Without a signed lralver from the subject of the regpes4 a 6 napiete griminal history record ztay not
be releasable, per Coda of low&, Chapter 692.2. Itor eem lets criminal hl9t0ry.recor0 tnlormaflon,w allowed bylaw, always
Obtain it waiver
si aturo from the sub ect of the request
Waryer.ReieaSe:ihercbytivepetmissionforthe' ibove rNuoninz official toconduct inlovn'mimingIno teeordcheckwithrheDivulwoferimival
Invexigi0an(=), Any criminal hlatorydata vonownin&m• tltmatn
rabyiheDUmeybemleaaedaselloweilbylaw.
Waiver Signature. .
As of O� _ . a search• of the provided name and date of birth revealed.-
No
evealed:
N'o Iowa Criminal history Reoord found wit1k DCI
Iowa Criminal Matory Record alta ed,'D'CI #
i;
DCI inidals
D0I-77 (08/25/10)
Received Time Nov.30. 2016 9:501M No. 3020
(DCI un only)
IX)
/41 ADO
SMARTER I SIMPLER I CUSTOMER DRIVEiI VU1NW'IDW�CjQ� C OV
Driver & IdeM6ieation Services
PO Box M I Des Mcirm IA 5WDG-9204
Phone 5115-Z14,9124 I Fax'515-739-08T
Certified Abstract of Driving Record
Inquiry Date: 11/30/2018 DL/ID #: 196AD8857(IA) Customer #: 3646257
Name: Kacer, Geoffrey Neil Class: D ID Status: None
Address: 2110 N DUBUQUE Audit #: 7518587 DL Status: VAL
ST
Issue Date: 11/12/2013 CDL Status: None
City/State: IOWA CITY, IA Expiration Date: 12/04/2018 CDL Cert Status: None
522451624
Endorsements: Chauffeur 3 CDL Med Status: None
Mailing Address: 2110 N DUBUQUE Restrictions: NONE Restriction None
ST Supplement:
Date of Birth: 12/04/1975
Mailing IOWA CITY, IA Sex: M
City/State: 522451624
History Information
Convictions
Citation Date
Conviction Date
ACD
I Explanation
lCounty
JUR
105 106/2014
105/23/2014
S92
Seed
Johnson
IA
Name: Kacer, Geoffrey Neil DL/ID: 196AD8857
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:
wQc�lytnT OF 7444�o 11/30/2018
Driver & Identification Services
�0�4L Do DV" Iowa Department of Transporation