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Home My WebLink About19-0174 1 r 1 CITY O IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX Last 1. Name (REQUIRED) l IDENTIFICATION NO. vl I (Office Use Onl ) 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 "reouired" information will result in denial of the aonlication First Middle -e 0(5 2. Address (REQUIRED) _ `j N- F✓DVi{ j{ I lnvfh �t�Je✓ /,�14 SZ�I 3. Contact Information (REQUIRED) Email: L6 -Cell Phone(-L�3' S w7 (All written communication 19ent via email) 4a. Driver's License expiration date (REQUIRED) °2x2012020 b. Taxicab Business Name (REQUIRED) Y -e i 7 iti Cvo 5. Prior experience in transportation of passengers: uhf r 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere ✓1'6 Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other ,�,_ i 7. Have you been arrested /charged with any traffic offenses in the last five years V'-\ D �o Tome of offense WhereWhen o `p t vvnat nappened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Otho 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? U e S W here Il n Tvoe of offense When - 05 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) FOR 04/2018 J* 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 Driver's license number C to o 3 issued on 23 expiring on b q2C> > n . I understand that if I falsely answer any questions in this application, that this applica on 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 prov' ' s o Title 5, C^ ter 2 of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant t�1 �� ,, ,r qty i�i�� `�—�'J Date �2 2 7 STATE OF IOWA ) COUNTY OF JOHNSON Subscribed and sworg. to before me by "5 -P " Q= C lA o. l Zrs on this day 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). Expiration date of Driver's license Signature of r design 02-26• Zolo oL L2- 201 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 Office Use Only Approved application DCI report State certified driving record Website update a -a8 -19 Date ae AxiwNsADGEnrmgzoiaeme�aoaDoc 04/2018 02. 1 eb- 20. 2019j� 2:45PhCab DCI IOWA � Vwv Ian Tv, ro�Dkvkjotj us zi 14 strtor Des bbjho�-J�wt (0,S .. 7 ;�MA 015) 125-OSO Fax SWE Or IOWA CriminatHmory pLeotd Check ReqUot Form . ' Owe No. 5778 P. fA)031933B'&,.• I L�002 DCI AccQuat-Number.- _9967-F (if Frolw Csb dl&a City 01 6wil C' P.O. �OX228'�� Iowa : YJA52244L Rhonar Yav (319) 3�39-7302 q� f . z) - c,5qz. bY;4w, always cord k Rud—U As of S2 'dM of bkth=vealad- 0 Uu0b of tha provood uzp o < ,ha 0 rr No 40wa:CzixdlnaaA0l7 RCC-Ordlolmd with DO rh DCI initials__ co q IM77 (=5110). Received Time Feb. 13. 2019 4:26PM No 4616 QIGWADOT SMARTER I SIMPLER I CUSTOMER DRIVEN www.'owadoiHgov Dranr & klanwica lon smbm PO Box 92M I Des Wnes. IA 5030&M Phare 51,-2.44-9124 1 Fax 515-239- 1837 Convictions Citation Date Certified Abstract of Driving Record I ACD Inquiry Date: 2/13/2019 DL/ID #: 060BB8663(IA) Customer tt: 4499323 Name: Chambers, Setoya Class: C ID Status: EXP Denise Address: 470 N Front St Audit #: 3606420 DL Status: VAL Issue Date: 02/13/2019 CDL Status: None City/State: North Llberty, IA Expiration Date: 02/26/2020 CDL Cert Status: None 523179451 Endorsements: NONE CDL Med Status: None Mailing Address: 470 N Front St Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 02/26/1992 Mailing North Liberty, IA Sex: F City/State: 523179451 History Information Convictions Citation Date I ConVletion Date I ACD I Explanation iCounty 3UR 110/27/2014 111/25/2014 S92 Seed Linn IA o n 7r1 Name: Chambers, Setoya Denise DL/ID: 060BB8663— - C-0 " Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa Department of:Franspofts4n, do hereby certify that I am the custodian of the records held by Driver & Identification Services, that this is a trda and accurate n 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: 2/13/2019 A2zlifn" Driver & Identification Services Iowa Department of Transporation AY [ --=J— Name: Chambers, Se[oya Denise DL/ID: 060BB8663