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HomeMy WebLinkAbout19-075r.1 � r CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 IDENTIFICATION NO. Ig -0 i (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) Failure to complete the "required" information will resuh in denial of the application Last First Middle (3 19) 356-5497 FAX 1. Name(REQUIRED) 'a�''��c-1 �y4i� 1UbNtJ(� yM\ij(LT`L 2. Address (REQUIRED) MA -S'b Wry' ±� ( —T- A S 2-2-`4� 3. Contact Information (REQUIRED) Email CrGrr\o , ru vin Cell Phone: '� \°\-3s6 -`j ZZ(o (AII written cbmrrOnication sent via email) ye WD w Q0. b i<_ 4a. Drivers License expiration date (REQUIRED) Ck - 23 -20 b. Taxicab Business Name (REQUIRED) �`R \\ew Q� 7-� --ro w cu c 1 5. Prior experience in transportation of passengers: 99 w s5 s cr vJ Nn,� C� 6. Have you ever been arrested / charged With any misdemeanors and/or felonies in this State or elsewhere? A j 6 Type of offense Where When E; --+ :-c What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended PleadGuilty`':"Oth(F 7. Have you been arrested / charged with any traffic offenses in the last five years? 1j0 0 Tvoe 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 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) 04/2018 ra 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 Departrpent of Transportation a valid Drivers license number { 3Z y y S� 0-1 issued on \\Q_expiring on 1( -Z3 - Zb. 1 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 p isions of Title 5, Chaptark7of the City Code. (Needs to be signed in front of a Notary Public) Signature of Appli Date /0 N O �D 0-..y.... STATE OF IOWA'— COUNTY OF JOHNSON ) �� M z' M Subscribed and sworn to before me by —)).AKn4t. 1�tu4ti��� this �_ day 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 or's license -Z. 3 ZCy Zy Signature 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. Approved application DCI report State certified driving record Website update CwtiT XIDRN94DGF M9201eamended.DOC Office Use Only l0-l(�-lei Date 04/2018 I ,qtr„ STATE OF IOWA Criminal History Record Check Request Form Mail or Fax cotnWaU, forms to: Iowa Dlv1e104 of criminal Iavosttgation Support Operations Bureau, In Floor 215 & r Street DesMoines,Iowa 50319 (515) 725-6066 (515) 725.6080 Fax ° -'z3 --19 ACT Account Number; 9967-F (faMUcable) lmd2m9ts to: Name Yellow Cab of lows Cl 0 Address P.O.9o%428 -' v Iowa, Iowa $2244' t2 Cn Phone X19) 338-9777 M t Fax 319-359-4142 a�'T ©Male �e�male I As of - �l , a eoarcll of the provided name and dad o Iowa. Criminal history Rocord found with DCI ❑ Iowa Criminal HistoryReoord attachtd, DCI DCI initials_r� DCI -77 (updated 06.26-2019) Received Time Sep, 21. 2019 9t09AM No. 1525 by � revealed; h�srod Cr `Y rosuif ?age 1 oft `'•, L :4UjM Uj `.F Cn U O co Q ?age 1 oft DISCLAIMER chis response can only Include public criminal history data. Under Iowa law, most juvenile records are confidential. Confidentlal 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 juvenAe records, if any, an application must be flied 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, htta://www.iowasexoffendercom/. 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 232.141(18). N O j C3 Y rn {per® Qx � — 0 M ;'A'Or�JWWADOT S!�l.�RIER I SIMPLER i CUSTOMER DRitlF ; WLmIOUVlBdC} gE3V DrNef & ldemifroatlon SeevioH I'U Eox AAs 1 Des Liclnea.. IA &Y306 -92M Phct}e 515-21:1-91741 Fax 513-739.4837 Certified Abstract of Driving Record Inquiry Date: 10/15/2019 DL/ID #: 432YY5707(IA) Customer #: 3875157 Name: Prymek, Donna Class: D ID Status: None Marie Address: 1129 KIRKWOOD Cf Audit #: 1373342 DL Status: VAL Issue Date: 10/18/2016 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 09/23/2020 CDL Cert Status: None 522405772 Endorsements: Chauffeur 3 CDL Med Status: None N 0 Mailing Address: 1129 KIRKWOOD CT Restrictions: Corrective Lenses Restriction lone �o Supplement: I -n CD Date of Birth: 09/23/1979 �„� C-1 t 9 Mailing IOWA CITY, [A Sex: F p� City/State: 522405772 —{C? Cr, 1 History Information o� CLEAR DRIVING RECORD O J Name: Prymek, Donna Marie DL/ID: 432YY5707 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: Prymek, Donna Marie DL/ID: 432YY5707 10/15/2019 Driver & Identification Services Iowa Department of Transporation �'-