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Home My WebLink About19-028� l l Y �III� Al CITY F IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 3 56- 5040 (3 19) 356-5497 FAX Last 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. L—D r;.f�j (Office Use Only) APP 11CA ISN FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) Failu e° t i`6i6&4 the "required" information will result in denial of the application First Middle 3. Contact Information (REQUIRED) Email: O r�ru G d�Ciml l . CSM Cell Phone: S(n�i' )4 - C} -i p`j (All wri mmunl�ion sent via email) 4a. Driver's License expiration date (REQ( b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? tAo Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other ,�1( 7. Have you been arrested / charged with any traffic offenses in the last five years? 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? N(J 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) o (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 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 P00C§ QH�19F REVIEW You must apply for an individual Department of Criminal Investigation Report (form available upon request). I hereby rt' that I have issued to me by the Iowa Department of Transportation a valid Driver's license number Li�� issued on xpiring on q -12-E22 . I understand that if 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 of a Notary Public) Signature of STATE OF IOWA ) COUNTY OF JOHNSON ) Date 3 L 2`r- 1 "1 and sworn to before me by 7irrR oU 4 P . Pu- rcS4, on this 'go( day of __.n WENDY S. 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' nse t7 cyct,i Signatu76 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 City Clerk or Office Use Only Approved application DCI report State certified driving record Website update Date CIerkrFA IMIVR4 Gi PPL920188m de .DOC 04/2018 #'k C4010WADOT?019�tY ,owa C/e k SMARTER I SIMPLER I CUSTOMER DRIVEN www.iowadot.gov e'tY Iowa Wow & IdeMakatlon Ssrvfoes PO Box 92M I Des Moines. IA 5000G92M Phone 515-244-91241 Fax 515-2391837 Certified Abstract of Driving Record Inquiry Date: 3/27/2019 DL/ID #: 433ZZ2783(IA) Customer #: 3086333 Name: Purdy, Rochelle Class: D ID Status: None Marie Address: 518 NICHOLS AVE Audit #: 2626679 DL Status: VAL Issue Date: 03/13/2018 CDL Status: None City/State: NICHOLS IA Expiration Date: 04/12/2023 CDL Cert Status: None 527667731 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: PO BOX 93 Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 04/12/1981 Mailing NICHOLS IA Sex: F City/State: 527660043 History Information CLEAR DRIVING RECORD Name: Purdy, Rochelle Marie DL/ID: 433ZZ2783 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: Name: Purdy, Rochelle Marie DL/ID: 433ZZ2783 3/27/2019 A5VZ�� Driver & Identification Services Iowa Department of Transporation 031Ma r. 25. 20191: 3: 38PM Cab DCI IOWA Q:AX)3193382No.1642 P. 2/3;1003 APR l . 019 STATE OF IOWA 'C/eek Criminal History Record Check' . �,q,, Request Form To: Iowa plvlslon of Criminai Investigation Support Operations Bureau, 1"Floor 21� E. 7' Street bey hfolnes, Iowa 50319 (515) 725-6066 (515) 725-6080 Fox e I am reauestina an lnwa r,.4...:...,i 1st_.__, .k.)?1:.��i.�(f. DCT Account Number; 9967-F (if epplicabla) From? Yellow Cab of Iowa City P.O. $ox 428 Iowa City, TA. 52244 (319) 338-9777 Phone: Fax: 19)339-7302 Last Name (maw `First Name mandatary) Middle Name (recomtnerided) r Date f B th (mr dem ,v"rendE:_, ac�.to So ' ' $ecuri Number (recommu aro l ❑Male Female `i Waiver Inforraatio8: Without a signed ,waiver from the subject of the request, a eomplgte g1ratnal history tecurd may not be releasable, per Code of Iowa, Chapter 692.2, For complete criminal history.reeord information, as allowed by Iaw, alwaya obtain a waiver si nature from the sub ect! f the re uoet Watyer.Fiekase: i twreby give r misalon for the 9bovo rcqucsdng eftiGiat to conduct an Iowa erirturw pistary record cheek with tiro olvblon of Ceimleai Invadgeuon (DCO. ropy admina hletary dear tronamin' me that Is melrgelnsa by the DCT pray be rdemcd asallmc4 by law, Waiver Signatures (DCI use only) As of a search of the provided name and date of birth ievealed• STATJ OF IOWP/DPS JN-� No Iowa Criminal Hlsttiry Record found with DCI ❑ Iowa Criminal Ristory•t'ecord attaohed,'DCI 9 Plv OF DCT initials DCI -77 (08/25/10) f Received Time Mar, 19, 2019' 1:07 No.0707 , 19 2019 UINAL'INVEST