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Home My WebLink About19-092,r CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 3S6-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. jCt— (Office se Only) APPLICATION FOR r dL6TORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 20! 4 t p�AAI irrie� Failure to complete 2 the r r f�r ron will result in denial of the analication CITY CLEM i�l 11 La.LasttA{Y, 10tA Middle 2. Address (REQUIRED) 3. Contact Information (REQUIRED) 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 'L 11 written communication se6Wvia emagr"A - . 5. Prior experience in transportation of passengers: f l 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Tvce of offense Where When What happened to the charge? (Circle one) ? Convicted Dis ssed Deferred/Suspended Plead w Other 7. Have you been arrested /charged wi any traffic offenses in the last five yea Type ofoffense Where When A What happened to the charge? (Circle one) Convicted Dismiss Deferred Suspended Plead Guilty Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 9. Have you ever applied to be an Other im If yes, please provide the name(s) 04/2018 Page 2 APPLICATION FOR TAXICAB VEHICLE DRIVER DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIER 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). 2019 NOV 26 PH 1: 13 I here4y certify that ave issued to me by the Iowa Department jqf Transportatio I'd iver's license number � ,'a P �(rPnlm issued on iS -Olo /LScpiring on r7,-,' ,6 understand that if I falsely answer any questions in this application, that this application may be denied. I agr fha 16 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) 111NI11.tf�flf.�'lfYftffH��f111f1�1tff111H1HNft41f11 NINNNNf.lfYffNNHNNtl1 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by on this 2 (,�� day of 1 �oueav*(1�r 2Qvt n e n _ CSI ASHLEY A JAY-PLATZ My Commission Expires .luly 14.2020 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 EDer's licege 2- o i- Z 7 'F7 tl-Z� fy Signaturedf 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 Gerkr IDRNaA GEAPPl9201&em ded DOC 0412018 ARTS Page 1 of 2 .41OWADOT - —F f7l; SMARTER I SIMPLER 1 CUSTOMER DRIM'`', nVjyK%* 14Vgdot. 9oV R - kNntirieaTon services l� 90: 9 P Ayaines, IA sQ=2oe P1_id(IB'S�S¢4i=St2a{Fac. 515 2M1837 Inquiry 11/23/2019 Date: Customer 5608287 Name: Philogene, Widmaier Certified Abstract of Driving Record DL/ID #: 787AK0765 (IA) CDL Permit Class: None Class: C Audit #: 4056687 Address: 927 BOSTON WAY APT Issue Date: 08/06/2019 12 City/State: CORALVILLE, IA Expiration 12/01/2027 Date: Endorsements: NONE Restrictions: NONE Restriction None Supplement: CDL Medical Examiner's Certificate CDL Permit Issue None Date: CDL Permit 522413159 Mailing 927 BOSTON WAY APT Address: 12 Mailing CORALVILLE, IA City/State: 522413159 Date of 12/1/1983 Birth: VAL Sex: M Expiration 12/01/2027 Date: Endorsements: NONE Restrictions: NONE Restriction None Supplement: CDL Medical Examiner's Certificate CDL Permit Issue None Date: CDL Permit None Expiration Date: None CDL Permit None Endorsements: Dowden CDL Permit None Restrictions: 9565950912 ID Status: VAL DL Status: VAL CDL Status: None CDL Permit ELG Status: Dowden CDL Cert Status: None CDL Med Status: Certified Certificate Specifics Explanations Medical Examiner First Name Ryan Medical Examiner Middle Name Matthew Medical Examiner Last Name Dowden Medical Examiner License Number 35434 Medical Examiner National Registry Number 9565950912 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 369-7211 Medical Examiner Type Medical Doctor Medical Certificate Issued Date 09/01/2015 Medical Certificate Expiration Date 09/01/2017 Date Added to CDLIS Driving Record 03/12/2016 History Information Convictions Citation Date Conviction Date ACD Explanation JUR County 03/05/2015 04/16/2015 S93 Speed IA Johnson 02/26/2016 05/26/2016 M75 Passing School Bus IA Johnson Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. httn•//l 79 ?9254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 11/23/2019 ARTS Accident Date ]UR Case Number 08/17/2019 IA 1129077 Sanctions Page 2 of 2 Type Effective End ACD Explanation ]UR Occurrence JUR Suspended 06/30/2016 '07/29/2016 ;M75 Serious Violation IA IA Name: Philogene, Widmaler DL/ID: 787AK0765 (IA) Pursuant to Iowa Code §321.10, 1, Darcy Doty, 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: Philogene, Widmaier DL/ID: 787AK0765 (IA) 1;2313i.!I0, I .I Wd 9Z h01610d 11/23/2019 d9nn.16-)L �� Driver & Identification Services Iowa Department of Transportation http://172.29.254.55/drivers/reports/customerhistorylcertifieddrivingrecord.ast)x 11/23/2019 s=.Nov. 26. 2019..11: 23AMc;t.rKDC1 IOWA 319 3666497 11,19,2019 10!4o. H19oo P. 1/2'002 !LE To: Iowa Division of Criminal Investigation Support Operations Bureau, l° Floor 215 E. 7`h Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax Tam renneariner an Tnwa r\iminal T-r:aa..... R.,....1 r`l...l-., DCI Account Number: (if applicable) From; _ City of lows City City Clerk's Office 410 E. Washington Street Iowa City, IA 52240 Phone: 319356-5041 Fax; 319-356-5497 Lastt Name (mandatory) Hirst Name (manda;arr) Middle Name (recenreended) Date of Birth (mandatory) Gender mandatory) Social Security Number racommended e� ❑Female Waiverinformattan: Without a Signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complota criminal history record information, as allowed by law, always obtain a waiver sf nature from the subject of the request. Waiver Release: l hereby give permission for the above rcVuling official to conduct an Iowa criminal history record check with the Divi;ion of Criminal investigation (DCI). My criminal history data concerning me Ibal Is maintained btthe DCI may be rcl . ed as allowed by law. Waiver Signature: • L"� v wmwnr ryl Iowa Criminal History Record Check Results As of , a search of the provided name and date of birth Ay sled: b4 . f,: `tea r'� No Iowa Iowa Criminal History Record found with DCT , a `c,a oC1 rn C9 ❑ Iowa Criminal History Record attached, DCI #n'ssa tiitt(yu `°`" uuugnnssddlt, DCI ilutials__Az___' DCI -77 (08125/10) Received Time Nov. 19. 2019 8:31AM k8884