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Home My WebLink About19-094+ J I r 1 CITY OF IOWA CITY 410 East Washington Streci Iowa City, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) _ IDENTIFICATION NO. I vl— b9q (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 result in denial of the application Last 3. Contact Information (REQUIRED) Email: First Middle 'l vy� e ) A 5 /ni ('Cell Phone:J� �9- r�� i- i%(3 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) F b. Taxicab Business Name (REQUIRED) IN 1 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?_ Tvce of offense Where When c� G^. What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any trafficoffensesin the last five years? i� 5 Type of offense 0 V a Where When W hat happened to the charge? (Circle one) onvicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license auffeur's license been suspended or revoked in the last five years? } (� Tvce of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? Ifs, please provide the name(s) n I O„ .- . A. n / REQUIRED 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 hpq(byy certify that I have issued t me by the Iowa Department of Transportation a valid Driver's license number f r�ton ✓t/ ��q, - issued on i�—) � expiring on ()o - I understand that if I falsely answer any questions int6isn, 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 Applicant e- v — �a�k+r�x��a-t+.:kx�exr,�+r+»�r�:m�tw�++�,r+��+•�N��a��a+eew:�++N��N��+++r�:�+ma:«�*�:��»��+��e��«��m«��r«aw�«��r�hr�«w�tw STATE OF IOWA ) COUNTY OF JOHNSON Subscribed and sworn to before me by on this day of ASHLEY A JAY-PLATZ 1 .C�d Q A Q .�i fn r. mfccinn No. 7115030 ftfotary Public in a tate of WWW July 14, 2020 ti I have reviewed this application, DCI report, and the State certified driving record of this applicant and h&e determined that there is no information which would indicate that the issuance would be detrimental to the safety, hea"81 welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration dateVofve,',snse !% 3 - 6*' -Z D Z 3 --+c-) cn p" SignaW 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. Office Use Only Approved application DCI report State certified driving record Website update Date GeA A%IDRN64DGE PPL92016ementlea.DOC 04/2018 iid—u- 3. 2019.112; 23PMCW DCI IOWA ffAW93M7,N2. 0354 P.. (/61006 STATE OF IOWA Criminal History Record Check Request Form I (Mail or Fax completed fo= to' Iowa Division of Criminal Investigation Rapport Operetious Bureau, 1" Floor 211 E, 7* Street Des Maines, Iowa 50319 (515)725-6066 (515) 725-6081) Fax ACIAccount Number, 9967-F (if apphable) godxl 4V d Name Xddn.Crb of Iowa City - Address P.O. B=424 Iowa City, Iowa 52244 _ Phone _(319) 336-9777 FAX 319-359-4142 Ll q nucy As of -3 _1 1 a search of the provided name asci date (Zf, ( 6?10WO No Iowa Criminal History Record found with DCI 2 1� p ❑ Iowa Criminal History Record attached, DCI 4 0 G „r DCI iniHals„�_ Disscl DCI -77 (updated 06.26-2016) Received Time Nov, 25, 2019 1:07PM No. 9137 (n -Cl we only) OF IOWAIPPS Q� ,2 5 2019 CAIMINAtINVEST Paas 1 oft 11!'01:,_ 3, 2019.112; 24;PM� pA100199�Z,�„ DCI IOWA No. 0354 P., 2/6� .. STATE OF IOWA Criminal History Record Check Request Form 1. Mail or Fax completed forme to: Iowa Dlvlelon of Criminal Investigation Support' Operations Bureau, 1" Floor 215 E. 7f° Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725.6080 Fax I am regUgsting an Iowa Criminal History Record Check om DQ AmuotNmubor: 9967-F 'Of tppBv,ble) 6endmvults to: Name Ydldw,Gab of low* City Address P,0. Box 428 Iowa City, Iowa 52244 Phone (319) 338-9777 Fax 319-3594142 Iowa Criminal History Record Check Resullts As of a search of the provided narlte and -a—No Iowa Criminal History Record found with Q Iowa Criminal Histoy Record attached, DCI DCI initials G' (DCC V" Ord DPS OF IOW V % 5 2019 Al. INVEST DCI -77 (updatsd 0(x26-2018) Page 1 012 Received Time Nov, 25, 2019 1:07PM No. 9"137 a r!6-01i'eYMIu. n a -•. � P. ° ! . �. PI• 1;_ bi; , � � � .'... .� `."•�:il°�1117T�T( sdbcinma,d 1 �� OMale EFemale ��v.. . , � �, i 4p, �ee"vrd Shay �. {iSk �. _ � '>;e',T. c � r �sai�"So,2't.'�„f�, •.r.:. •. ti .,. ,o .. .. .° jr ` �b,t7<�rfSt3a3oa Or,'• x x A�m�� r Iowa Criminal History Record Check Resullts As of a search of the provided narlte and -a—No Iowa Criminal History Record found with Q Iowa Criminal Histoy Record attached, DCI DCI initials G' (DCC V" Ord DPS OF IOW V % 5 2019 Al. INVEST DCI -77 (updatsd 0(x26-2018) Page 1 012 Received Time Nov, 25, 2019 1:07PM No. 9"137 111.Dec. 12019112; 24PMCab DCI IOWA fAM9Mgr�o. 0354 P,r 3�6jooS STATE OF IOWA AL Criminal History Record Check Request Form Iowa Division of Criminal investigation Sapport Operations Bureatt, P Floor 215 E. 7m Street Des Moines, Iowa 50319 (M) 725-6066 (515) 725-6080 FaX DO Account Number. 9967-P (If WpUuble) Sendre9lllt6 z Name Xemaw Cab of Tolva City Addresq Y.O. T3ox 426 Iowa City, Town 52244 Phone .(319)338-9777 Fax 319-359-4142 yyc - � � ia4GV4 ;.{ \.i 11GVA �.�Vvtasaa �lyp� ' \1V\1\11111111111ggIHll!"' A9 of a acarch of the provided name and date,44A�Or . s 1F IOWA/OPS Q No Iowa Criminal History RecoXd fOtuad with DCI, ' N,: rJ� V .2 5 2019 ❑ ii INV Iowa Ctimiaei Mstory Record attached, DCI # i` :'%a %j 4 .;u'•1AL CSY; DCI initials_ r `. , ....•.`racy \r• 13CI-77 (updated 06-26-2018) Page 1 oft Received Time Nov.15, 2019 1;07PM No -9737 CIJIGWADOT SMARTER I SIMPLER I CUSTOMER DRIVEN www•IOwadogov Dwee a kw l 4atlon sankas PO Box 9204 I Des Mofnas, IA 50306-9281 Phone 515-234.91241 Fax 515.299-1837 Certified Abstract of Driving Record Inquiry Date: 11/25/2019 DL/ID #: 839ZZ1171(IA) Customer #: 1225050 07 03 2015 Name: Ojeda, Adriana Class: C ID Status: None Address: 107 2nd Ave Apt 26 Audit #: 2194984 DL Status: VAL Issue Date: 09/30/2017 CDL Status: None City/State: Coralville IA 522412659 Expiration Date: 03/04/2023 CDL Cert Status: None Endorsements: NONE CDL Med Status: Nonce— .o Mailing Address: 107 2nd Ave Apt 26 Restrictions: Corrective Lenses Restriction NondD Supplement: Date of Birth: 03/04/1959 Mailing Coralville IA Sex: F DC7 cel F City/State: 52241269 =gym m History Information .77 Co Convictions Citation Date I Conviction Date I ACD Explanation IC*untv 7UR 07 03 2015 107/21/2015 1 B64 No Insurance Card Tama IA Name: Ojeda, Adriana DL/ID: 839ZZ1171 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: 11/25/2019 6/AJ Cosi! Driver & Identification Services Iowa Department of Transporation