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Home My WebLink About19-074t b. Taxicab Business Name (REQUIRED) JCll(, 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? r�jJ r.o Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested I charged with any traffic offenses in the last five years? TV J Type of offense What happened to the charge? (Circle one) Where When 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? *C, 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 04/2018 IDENTIFICATION NO. 'q'b-7 _I 1 1 (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 street Failure to complete the "required" information will result in denial of the application Iowa City, Iowa 52240-1826 (319) 356-5040 Last First Middle (319) 356-5497 FAX 11 n 1. Name(REQUIRED) �YY�l�in`-�kTc &y e(— {�ll(t(C %& IZEnw 2. Address (REQUIRED) -z-) � U!�) LV_1(, M -(bd Q ` s of r 6�A ' V4 (� 1 3. Contact Information (REQUIRED) Email: 1&Irc \o,Qr. \r\-,0 f? dry o ,(, 6A n Cell Phoone: 31�-SLI (Z3% (AII written communication sent via email) 4a. Driver's License expiration date (REQUIRED) rr- z9A4 b. Taxicab Business Name (REQUIRED) JCll(, 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? r�jJ r.o Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested I charged with any traffic offenses in the last five years? TV J Type of offense What happened to the charge? (Circle one) Where When 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? *C, 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 04/2018 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 hereby certify that I have issued to me by the Iowa Department of Transportation a valiq Driver's license number 9'V) A -WI "11 o issued on W zu expiring onI III 2� . I understand that ff 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, H authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Title P, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) moi.. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by " a LA on this 3� day of C,ciotc, - ,2019 n .n n. n IZ .o I have reviewed this application, DCI report, and the State certified driving record of this appy" ntandfMve date ined that there is no information which would indicate that the issuance would be detrimental to the sa•�eat—I-Fri or wetwe of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). m � rn Expiration date of Driver's license 7r _ /04/0 Si of Mice Chief or designee IDat 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 aed AXIDRIVB4 G PP19201Umended.DOC 04/2018 tirPur ASHLEY A JAY-PLATZ Notary Public in he State I My CommssionE;ires rows Jul 14, 2020 N .o I have reviewed this application, DCI report, and the State certified driving record of this appy" ntandfMve date ined that there is no information which would indicate that the issuance would be detrimental to the sa•�eat—I-Fri or wetwe of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). m � rn Expiration date of Driver's license 7r _ /04/0 Si of Mice Chief or designee IDat 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 aed AXIDRIVB4 G PP19201Umended.DOC 04/2018 I Oct. 9.20192:29PMDCI IOWA ffAW'3rNw.3274 P•, 112j002 STATE OF IOWA Criminal History Record Check Request Form Mail or Fax comnlott'/i 40F>b16 to: Iowa Division of Criminal Investigation Support Operations Bureau, P Floor 215 8. 7a' Street Dae Molnar, Iowa 5031➢ (515)725-6066 (515) 725-6080 Fax a DCI Account Vnmber: 9967-F (¢oppfi aUc) Send results to: Name 'Poliow Cab of Iowa Cf Address P.O.Bor428 Iowa City, Iowa 52244 Phone, (319) 338-9777 Fax 319-359.4142 ..o ioiya urimixtal tustory Kecoray..ug, 1i iir, "''., (DClwa"in As of �' 1 a search of the provided na ie�hgd date otbirth ihV1d&l`9# i`V;(nVl � j ATE OF IOWA/DPS No Iowa Criminal History Record found with DCI :: c:C'; ``' r' OCT 0 2 2019 ❑ Iowa Criminal History Record attached, /DCI # DIV F CRIMINAL INVEST DCI initials v DCI -77 (updated 06-26.2DI8). Received Time Oct. 2. 2019 12;36PM No.2106 Page 1 of Oct. 9.2019 2:30PM DCI IOWA No.3274 P. 2/2 DISCLAIMER 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 authorization 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 Sex Offender Registry: http://www.lowasexoffender.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 confidentlal juvenile records, If any, an application must be filed pursuant to Iowa Code section 232.147(18). N O O C7 �1 m 'n �L h O N r. 1W, boor SMARTER 15141PI,ER C (USTOWR URIVEN VU4 lWu.Et7Uil8dO C1V Df?.,ea & iden irucauon services PO ecx 920a I Des Mines. IA °.,OQDS•Y2W Phone Sl&244.91241 Fax: 315-239.1897 Certified Abstract of Driving Record Inquiry Date: 10/9/2019 DL/ID #: 989AM7107 (IA) Customer #: 6191104 Name: Smith -Burkhalter, -: Class: C ID Status: VAL IUR Marcia Renae ___4 09/24/2018 01/17/2019 D53 Address: 3503 Shamrock PI Audit #: 3555262 DL Status: VAL Iowa Fine Issue Date: 01/18/2019 CDL Status: None City/State: Iowa City, IA Expiration Date: 10/18/2024 CDL Cert Status: None 522455137 Endorsements: NONE CDL Med Status: None Mailing Address: 3503 Shamrock PI Restrictions: NONE Restriction None Supplement: Date of Birth: 10/18/1992 Mailing Iowa City IA Sex: F City/State: 5224551J7 History Information Convictions N 0 CD Citation Date lConviction Date ACD I Explanation Countv R --1 05/01/2018 06/16/2018 NOS Fall to Yield Right of Johnson _ r IUR Wa ___4 rn r JrD Accidents - Accident involvement indicated does NOT mean the individual was at CD fault or given a citation. — Accident Date M1` Case Number )UR OS O1 2018 J1045357 Explanation IA Sanctions Type Effective End ACD Explanation Occurrence 3UR IUR Suspended 09/24/2018 01/17/2019 D53 Non -Payment of IA IA Iowa Fine Name: Smith-Buckhalter, Marcia Renae ADL/ID: 989AM7107 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 lit 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: , 0. 1,OSHT OF 74r 10/9/2019 O � a t4 z Driver & Identification Services �kL DCYG Iowa Department of Transporation Name: Smith-Buckhalter, Marcia Renae DL/ID: 989AM7107 911 Q (-) b n �C--) r = M p�