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Home My WebLink About19-022IDENTIFICATION NO. �— w (Office Use Only) MAR 2 01619 APPLICATIW,FPR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Dq""pnRlevI must be made between 8 a.m. to 3 p.m., Monday — Friday) CITY OF IOWA CITY 410 East Washington street Failure to complete the "required" information will result in denial of the application Iowa City, Iowa 52240-1826 (319) 356-5040 (3 19) 356-5497 FAX First Middle Last e/f AL n/ Tzorf4E12f✓)�� 1. Name (REQUIRED)(Fiy� �(jjtl /tel) 2. Address /fi 3. Contact Information (REQUIRED) Email: _df FfAeyr d-QAf//nL/& r/ &16ell Phone: 3)p f Sly gI�/ (All writtn communication senTvia email) 4a. Driver's License expiration date (REQUIRED) 02 h& 12c221 b. Taxicab Business Name (REQUIRED) 4-1,0 yr 5. Prior experience in transportation of passengers: 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When a What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Other 7. Have you been arrested/ charged with any traffic offenses in the last five years? k Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other �l 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years 0 Type 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) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 MA DEPARTMENT OF CRIMINAL INVESTIGATION (DCQ REPOfr LAND 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 here y� rfY th I I have issued to me by the Iowa D pa ej}t of Transportatio a alid river's license number ? ggg y (I /7 issued on of 3i get on o?� I iB . I understand that if I falsely answer any questions in this application, that this ap Ii ion may be denied. I agre 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 o 'tle 5, Chapter 2,?f the C4 Code. (Needs to be signed in front of a,Notary Public) Signature of Applican Date/ ff11f1f1ffflfN{N11ff1fff1f1f1,y}fiylfHf11fflyf}tffffffflrlf�yyfylfnfflffllYlHyyff Ylff fffffffff�•kkffffff STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by �4 ( ,4 e efrn �� on this ab day of � a� , r._& swl ! 4 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 Drig 0 Z —16 - z, z / a 3- ?c--1 9 Signa a 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. Office Use Only Approved application DCI report State certified driving record Website update 3`_�O\k Dte aenNAXIDRIVBADGenPPLe201ea, ded.Doc 04/2018 Mar.14.2019 5:45PM 03/11/2019 0834 Yellow Cab DCI IOWA No. 0191 fAM19 938 2M NAR 2 0 Y019 STATE OF IOWA t . Criminal History Record C C�Clerk Request Form Y, Iowa P. 1/2 P.0021002 DCI Account Number: ,9967-P.. .9' (ifeODlfabla .) To: Iowa Division of Crltninal Investfgation 1 Support Operations Buroau, III-Voor From: •fellow Cab of Iowa City, 215 E. 7" Street P.O. Box 428 Des Moines, Iowa 50319 (515) 725-6066 10Wa City, LL 52244 (515) 725-6080 Fax (31 9) 338-9777 Phone: Fax: (379)339-7302 I am re usstin an Iowa Criminai HistoryRecord Check on: 1 RLast7�� Name ntandatoM prsst NraLme� (mandato y s4A Q! 7' " .I C'lp� Iry/ice L// (rewmmeode0 GI.N / (�L.y 6 Date of Birth (lanaacory) Creader (mmaero `�� Soolel-Securt Numbsb' r, mwl wae od ��" `lY ICj / /,(YJ ale Female ✓�� CVLS/ Waiver jnfOr)7satlon: Gl�lthout a signed *liver from the subject of the regpast, a comp igte criminal history record may not be releasable, or Code of lows, Chapter 69.2.2, For complete criminal histo obtain a waiver at nature from " ryrscord luform Ooa, aq allowed "by low, Always the sub eetaf the r west. Wdlver,Release: i hereby awe t =WOn for the: above Jnveui`itlea (Da). «gaesringo al to Band= w Iowa aiminal Money record cheek with the Division ofCrownel MyatunlnelhlateryA.noenoamingmothat' b lboDa be telat, t . I0 a riminal Illstox Roc 1 d Check Results v(f)CI uaa may) As a searob of the provided name and dare of birth revealed: o y No lows Crimina] History Record found with DCI ; . 00 ' o{4 ❑ Towa Criminal I• ao Z ty F�ecord attaehed,'DCI # � DCI initials ACI -77-(08/.25/10) n --...."J T'-- u-- 11 1n,n 0. 9n AAt AI. Mcn ' FILE® MAR 2 0 L919 1UWA Liu I l aitY Clerk �adotaov CLEAR DRIVING RECORD Name: Rothermel, Jeffrey Alan DL/ID: 198BB4017 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 1 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: Rothermel, Jeffrey Alan DL/ID: 198BB4017 3/11/2019 Driver & Identification Services Iowa Department of Transporatlon SMARTER I SIMPiER I CUSTOMER DRIVEN Dnyw & ldonWW dao Smilm PO Box 92M I Des Moines- IA 5030PM Phone 515.244-91241 Fax 515.2$1837 Certified Abstract of Driving Record Inquiry Date: 3/11/2019 DL/ID #: 198BB4017 (IA) Customer #: 3866674 Name: Rothermel, Jeffrey Class: C ID Status: None Alan Address: 2024 SHERMAN DR Audit #: 9749361 DL Status: VAL Issue Date: 01/31/2016 CDL Status: None City/State: IOWA CIN, IA Expiration Date: 02/16/2021 CDL Cert Status: None 522404768 Endorsements: NONE CDL Med Status: None Mailing Address: 2024 SHERMAN DR Restrictions: NONE Restriction None Supplement: Date of Birth: 02/16/1965 Mailing IOWA CITY, IA Sex: M city/State: 522404768 History Information CLEAR DRIVING RECORD Name: Rothermel, Jeffrey Alan DL/ID: 198BB4017 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 1 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: Rothermel, Jeffrey Alan DL/ID: 198BB4017 3/11/2019 Driver & Identification Services Iowa Department of Transporatlon