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Home My WebLink About19-020IDENTIFICATION NO. —D 1 l 1 (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) CITY OF IOWA CITY 410 East Washington 5trcet Failure to complete the "required" information will result in denial of the application Iowa City, Iowa 52240-1826 (319) 3S6-5040 (3 19) 356-5497 FAX C, 1. Name (REQUIRED) �e�� lJ�✓� 2. Address (REQUIRED) 400 3. Contact Information (REQUIRED) Email: 4a. Driver's License expiration date (REQUIRED) _ b. Taxicab Business Name (REQUIRED) —/L 5. Prior experience in transportation of passengers: U✓ �irst Middle sent 3 ?- oa lDw C'6,k, Phone: 3 / - 777- )19 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or 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? 0 0 Type of offense Where When 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 H so &j V/' f --�)A ', 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) �j C) 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 herg cert' that I h ve issued to me by the Iowa ep rttn t of Transpo tion a va' river's license number �l (� l� �d— issued on - I / expiring on , n- I understand that if I 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, Chapter 2, of the City Code. (Needs to be signed in front a Notary Public) Signature of Applicant (N Date / /ok STATE OF IOWA ) vd COUNTY OF JOHNSON 1 Subscribed and sworn to before me by'%fa 1, S C on this t ( day of LAa <6 4�_ ala 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' license d 3 -0-Z� 7 Sig re 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. Of v Office Use Only Approved application DCI report State certified driving record Website update -ice-I q Date CJWTAXIDRWBADGEAPP gMl8s endo DDC 04/2018 Nor. 5. 20 19 9:72AM DC1 10WA No. 8087 P. i ...ny Clerk ver roe: 916 3666467 02/21/ 010 14:40 edam 1.,61;/002 tVgP A rVW #-%V7 7l 111 r A ne�SLVL)I/»1 0 ALait1 WA' I" try L't, Criminal History Recoyrd Check Request Form' ' DCI Account Number: y/? o A - F (if applicabh) To: Iowa Division of Criminal Investigation support Operations Bureau, I" Floor 215 L Th Street Des Moines, Iowa 50319 (515) 725.6066 (515) 725-6050 Fax I am reauestine an Iowa Criminal History Reenrri rh.rk nn From., City of Iowa City City Clerk's Office 410E. Washington Street e® Iowa City, IA 52240 q409 Phone: 319-356-5041 �d �C ?�!� Fax; 319-356-5497 �d rm.ndm Last Namemv) ............x.. nYC{N9.xn,---.-.--., __....�...� ,....,.,..,..,,r wr:� s_ur - a.aluuac ilausc tmconuumixa) Date of Birth(mandatory)Gender (mandatory) Social SecurityNumber (recommended) , /q (q f �vV 10 ale ❑Female ` 7j7i I " I q— y U Waiver Information: Without a signed waiver from the subject of the request a complete criminal histnry r. ... A . ,... . be releasable, per Code of Iowa, Chapter 692.2. For eom etc criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request WalVa Release; I hereby give permission for the above requesting official to Wriducl an lmva climitul history record cheek with the Division of Qsminal investigation (DCI). Any alminal history data anceming r is maintshird by the DCi may be relascd as allowed by law. Waiver Signature; Oti. e A Iowa Criminal History Record Check Rem» Itc ` (DCi use only) As of a \1� (� A cParnh of thn ..e...,i.i.A tie u nn l iMa F 0.: e1........,,r..A. V,1 TL VF i4iv'n%MOO ❑ No Iowa Crirninal T-Tistory Record fowfd with DCI I FEB 21 2019 ¢� D V OF CRIMINAL (y6' Iowa CriminalT-Tistory Record attached, DCT 42,15C(515 1 DCI uutials__hE5= UG1= / / (V 511J/ 10) Received Time Feb. 21. 2019 2:40PM No. 6047 Mar, h.2019 9;h9AM UGI IUWA IOWA CRIMINAL HISTORY DCI 00951853 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 2 DATE PRINTED - 2019/02/27 DCI:00951853 NAME: PEDERSON,TRAV PEDERSON,TRAVIS CLARK DOB SEK RAC HGT WGT EYE NAIR SKN POB 19910300 M W 511 175 HAZ ERO FAR IA ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y TAT L ARM TAT R ARM CCH RECORD *** 01 ARRESTED/TAKEN INTO CUSTODY 20120305 AGENCY: IA0180100 CHEROKEE PD CHARGE NO- 01 IA STATUTE IA708.2(2) ASSAULT CAUSING BODILY INJURY -1978 TRK#: 089158201 COURT DISPOSITION AGENCY: IA018015J CHEROKEE CO DIST COURT COUNT NO- 01 IA STATUTE: IA708.2(6) ASSAULT No. M/ Y. Z COURT CASE Ib; 03101 SRCA024388 /p CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 069150201 RESTITUTION �p SENTENCE DISP APF DAT �d FINE $65 20121012 02 ARRESTED/TAKEN INTO CUSTODY 20121223 AGENCY: IA0710000 OBRIEN CO 80 CHARGE NO- 01 IA STATUTE IA123.46 CONSUMPTION / INTOXICATION - 1976 TRK#: KL0017901 COURT DISPOSITION AGENCY: IA071015J OBRIEN CO DIST COURT COUNT NO- 01 IA STATUTE: IA123.46 CONSUMPTION / INTOXICATION - 1978 COURT CASE ID: 03711 SMSM024137 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: KL0017901 SENTENCE DISP EFF DAT FINE $65 20121224 An arrest without disposition is not an indication of guilt. This record rt_i—d M. the TCCJa Ti..ie ..n of !`riminal Yn roehinafinn Ail real of Identification is a public record but can only be released to non-laW enforcement agencies by the DCI. W war. 5, 2019 9:53AM DC1 IOWA No, 8081 P. 3 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 author12ation 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 Sax Offender Registry: http://www.iowaaexoffender.com/ . However, even though some information is available on this site, the actual records for juveniles 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). IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION ClJ10WADOT wad SMARTER I SIMPLER I CUSTOMER !}RIVEN www.iowadot.gov DfNsf & IdaintikaUon Ssn[c" PO Sox M I Des IlAcinm IA 503069201 Phone 515-215-9124 1 Fax 51;,239.ISS7 Certified Abstract of Driving Record Inquiry Date: 3/11/2019 DL/ID #: 486AF7752(IA) Customer #: 5780588 Name: Pederson, Travis Class: D ID Status: VAL Clark Address: 1100 Arthur St Apt Audit #: 2552799 DL Status: VAL K3 Issue Date: 02/15/2018 CDL Status: None City/State: Iowa City IA Expiration Date: 03/08/2024 CDL Cert Status: None 522406615 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: 1100 Arthur St Apt Restrictions: NONE Restriction NWe K3 Supplement: f " Date of Birth: 03/08/1991 - Mailing Iowa City IA Sex: M City/State: 522406615 f, History Information I Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number lUR 110/1912018 1073952 IIA Sanctions Type Effective End ACD Explanation Occurrence 3UR 7UR Suspended 08/11/2017 08/13/2017 D51 Non -Payment of IA IA Child Support Suspended 01/17/2018 02/04/2018 D51 Non -Payment of IA IA Child Support Name: Pederson, Travis Clark DL/ID: 486AF7752 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: Name: Pederson, Travis Clark DL/ID: 486AF7752 3/11/2019 C� Driver & Identification Services Iowa Department of Transporation *49 41�40 I �o�ya �1y cue 1p/9 /04 a