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IDENTIFICATION NO. 11 --0(09
(Office Use Only)
.� APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Strcct Failure to complete the "required" information will result in denial of the application
Iowa City, Iowa 52240-1826
(319) 356-SO40 Last First Middle
(319) 356-5497 FAX r /'� /'
1. Name(REQUIRED) [_� jatX91n i1'0`h 6
1r
2. Address (REQUIRED) _:Rqa1,qr
3. Contact Information (REQUIRED) Email: t Cell Phone:
*nwriftlen CG1nMUn1iWi64 sent via email)
4a. Driver's License expiration date (REQU
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?
Type of offense Where When
N
City, Iowa
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead GuiltyOther
7. Have you been arrested / charged with any traffic offenses in the last five years? /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? h
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)
A
I_," I Ilk Pj
04/2018
10
Page 2
APPLICATION FOR TAXICAB VEHICLE DRIVER
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 Mgt' that I have issued to me by the Iowa a art e t of Transportati n a valid Driver's license number
�� /2 . % 99 issued on ; = expiring on �� . 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 provisj�Title P upper 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant '-- Date
HHfYlfHllifHffll!llfifl*f*ifM***ti*H*H!HllfHffHHHHfllHff*}*H**ffi-IlHHH1HMIHH*1}*f11HlHfH1fH**lllHffffHlHf!*I}* k!}!!
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscri and sworn to before me by u s, 5 . M. 7i e l oo ub'_ on this �Lo day of
I have reviewed this application, DCI report, and the State certifiedgliv iq9(e applicant and have determined that
there is no information which would indicate that the issuance woul{be1l n I e safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code). 99 !!
Expiration date of Driye ' 'dense 06-30--;rjZ 3
SEP 2 01019
}crN
Iowa City, Iowa
S' na: 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.
q-ao -1 9
Date
lHeH}e*4fif lfff4et44Htff4fH4L4HYt4lf f flfllfHHlH11HllHHlfff 1flHlHfH4Hf ff11f1fN1flHfflfff4fHM1-lffffHHH*Iff f *lffffflff4*�f4*f
/ Office Use Only
Approved application ,/
DCI report �—
State certified driving record
Website update
aeMffMIDRNSH GEA L92018sm nded.DOC 04/2018
09)1UJZUIV201IJ:aei3MwCab DCI IOWA
STATE OF IOIWA.
Request Foran
To: Iowa Misiom of Criminal Iorvestigation
Support Operations Ba> �a
L
218 B. Tr Street
Das Moimea, Iowa 50319
(51;0 736.6066
(m) 7266010 Fax SEP 2 U 1U19
City Clerk
Iowa City, Iowa
Ian reaubdin¢ an lava rTimtn.l S nma * a..r vi rt..nl. n...
0'2)0319 M 2Nito 9 7 7 6 P. r.uuM03
DCI AowuntNmaber: _9967•F
(trowilatbw)
From; Yellow Cob of Iowa City
Y.O. Box 428
Iowa City, IA. 52244
(319) 338-9777
hhome: '
(319) 3394302
Diet Name from
Tk sY Namo tmad
M�f Name reaoelo,am
)
J�N.L-hal
�ason
idle
Tia .n� - rlGulr,t�
Date of Birth a
Creader
soew Soo N er ftemmmmmiA
0B/30 90-5
Male
❑Eeraale
��-t "7a�aieSjP
walverfkformatlon: Without a signed watwr from the subject dtbe regaasy a domplate crimimmi history record may not
be Mehambie, per Code of Iowa, Chepter 8923. Forte criminrl hhtory record lulbrmatioo. as a0ovred by Jew, ah ,"s
obtaw a waiver sigmalare from the subject or the request.
waiver Aef=et l herely etva pwmbr M Rr the abovr ragatedn al m
1nvaUµdoa (DCl) Airy orMlnal hlm0rj dq eooauh @ by
owuhm m lover mbdam hiwowr rd dwk wbh the Divixbm of nrWaal
qCl be mi"* a sUmad by hnv.
WatberSigrratans:
,101
AS of ``� i ° ("I iiiti irf;
a watt h of the provided name and date of birth reveaGl« . 0 ... OF 1V
No Iowa Ce ainal Motory Reoord fotmd with DCT -SEPc. � 1� `•
011 UNAL INS
❑ Iowa Cr{minal MatW Record attached, DC1 #
"••.11..�..m. ••• oX
DW p"Is00`\5"`4",
DCI -77 (08/25/10)
Received Time Sep. 10. 2019 1:33PM No.8480
C400 %,d
410WADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN
www.iDwadot.gav
Driver d Idmitfi ation Servicas
PO Box 92041 Des (Acmes. IA 503C6.9 -V4
Phone: 315-240-91241 Fax 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
9/10/2019
DL/ID #:
508AG5698 (IA)
Customer #: 5811085
Name:
Deloach, Jason
Class:
B
ID Status: EXP
Stafford Maurice
Address:
2826 WHISPERING
Audit #:
2544119
DL Status: VAL
MEADOW DR
Issue Date:
02/13/2018
CDL Status: ELG
City/State:
IOWA CITY, IA
Expiration Date:
08/30/2023
CDL Cert Status: None
522406828
Endorsements:
Passenger, School
CDL Med Status: None
Bus
Mailing Address:
2826 WHISPERING
Restrictions:
Automatic
Restriction None
MEADOW DR
Transmission, No
Supplement:
Manual
Transmission
Equipped CMV, No
Class A Passenger
FILED
Vehicle
Date of Birth:
08/30/1983
Mailing
IOWA CITY, IA
Sex:
M
SEP 2 0703
City/State:
522406828
City Clerk
Iowa City, Iowa
CDL Medical Examiner's Certificate
Certificate Specifics
Explanations
Type
Down rade
DowngradeStartDate
08/03/2019
IssuingStateCode
IA
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
3uR
10§115/2018
1052882
IA
Name: Deloach, Jason Stafford Maurice DL/ID: 508AGS698
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: Deloach, Jason Stafford Maurice DL/ID: 508AG5698
9/10/2019
C�
Driver & Identification Services
Iowa Department of Transporation
FILE®
SEP 2 0 203
City Clerk
Iowa City, Iowa