HomeMy WebLinkAbout19-001CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(3 19) 3S6-5497 FAX
Last
1. Name (REQUIRED)
IDENTIFICATION NO. I (?-
(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)
"r�uiFailure to to complete the "r�uired" information will result in denial of the application
red" information will result in denial of the application
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email:
email)
4a. Driver's License expiration date (REQUIRE ) +1U�`1
b. Taxicab Business Name (REQUIRED) lu
5. Prior experience in transportation of passengers: 2
Phone:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Tvce of offense Where
What happened to the charge? (Circle one)
When
0
i
-_ ra
c
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested I charged with any traffic offenses in the last five years? ( /C5
TT of offense Where When r
What ha r
peened to the charge? (Circle one)
Conic 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? ]p
Tvce 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)
r e
FOR
04/2018
U
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 herebx ce hat I have issued to me by the Iowa D a ment of Transportat n valid Driver's license number
76 % V V 7 Z:O issued on ti expiring o I understand that if I
falsely an w r any questions in this application, that this app if
may be deniedA agree t at 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 provisio Title 5, Chapter 2, the City Code. (Needs to be ssii n in front of a Notary Public)
Signature of Applican Date //G
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by e X o -ca on this 2 day of
Q
MNDY
the
I have reviewed this application, DCI report, and the State certified driving record of this applicant and five determined that
there is no information which would indicate that the issuance would be detrimental to the safety, healt_ welfare of d th
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
_c' a
esi-
Expiration date o�riy#ft license !I�%-3Q- Z —'oma w [—
�7 M
/-2-l9 w
Signature of Police Chief or designee Date y -
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.
Clerk or
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
Ge,k/ IDRIVaaDG PPL9201UMendedDOC 04/20t8
Q4001 ooT
SMARTER I SIMPLER I CUSTOMER DRIVEN vvww.lowadot.gov
Drhw 8ldenUkauon Smit"
PO Box 92041 Des Manes. IA 5MMS2W
Phone 515-233-9124 1 Fax 51'23&1837
Certified Abstract of Driving Record
Inquiry Date: 12/21/2018 DL/ID #: 769YY3726(IA) Customer #: 677799
Name: Koedam, Jeremy Class: D ID Status: None
Jonas
Address: 518 NICHOLS AVE Audit •: 1542972 DL Status: VAL
Issue Date: 01/11/2017 CDL Status: None
City/State: NICHOLS IA Expiration Date: 04/30/2021 CDL Cert Status: None
5276677f1
Mailing Address: PO BOX 93
Mailing NICHOLS, IA
City/State: 527660093
Convictions
Endorsements: Chauffeur 3
Restrictions: NONE
Date of Birth: 04/30/1982
Sex: M
History Information
CDL Med Status:
None
Restriction
None
Supplement:
Fail to Obey Traffic Johnson! -1:) t i
N
Si n SI nal
O
�O
Citation Data
Conviction Date ACD
Explanation Coun" 1 IUR 1
07/16/2017
08/03/2017 M14
Fail to Obey Traffic Johnson! -1:) t i
Si n SI nal
C.)
N
Name: Koedam, Jeremy Jonas DL/ID: 769YY3726
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:
12/21/2018
A2Z21r
Driver & Identification Services
Iowa Department of Transporation
Dec.26.2018 2:37PM DCI IOWA
12/2112018 14:52 Yellow Cab
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