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Home My WebLink About19-102IDENTIFICATION NO. IA - In -,2 - (Office O2(Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 6 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 (3 19) 356-5040 Last First Middle (319) 356-5497 FAX 1. Name (REQUIRED) /<O eCla m 1 J00c; S 2. Address (REQUIRED) �1 %�11 C�olS ✓e /�/l,`c I�C�S S/T .SZ7GC1P-4i?Lx- c? 3. Contact Information (REQUIRED) Email } f dl. rnd kc ec(ar., o �/a kv ccs Cell Phone: �3/(O35G (All writt n communication sent via email) 4a. Driver's License expiration date (REQUI /RE //D) U y�S(�� b. Taxicab Business Name (REQUIRED) V—e /tCZ.J 1/C-, 6 1 5. Prior experience in transportation of passengers: A l wtt ,4 3 if /F r, 1--s 6,J , l/i 1(oL � (a 1 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? / Type of offense Where When. _O What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Where 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? /UC 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) SIGNATURE AND 04/2018 r 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 D partment of Transportati n ja valid Driver's license number '7 6151 V(/3 � 2 f, issued onj1t112c,j xpiring on 6 ° ZcZ . I understand that if I falsely answ r 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applica kiy, Date/ 7 z7 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribedandsworn before me by .) P <P%" �. Kc)£0CVLA on this c� 4� day of "A WENUY s. OAYER RoTary Publ' in and for the Stat ofti§wa r I have reviewed this application, DCI report, and the State certified driving record of this applida'niandi9eve determined that there is no information which would indicate that the issuance would be detrimental to the safety, heahor welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Driver's license Signature atfildor designee ate ' h 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. of City Clerk or Office Use Only Approved application DCI report State certified driving record Website update X-7 Date a.rkrrMIDRWaADGEAPPL92018amanded.DOC 04/2018 `9920e_c._1.3.2019__10;15AMCab DCI IOWA ffA*3183302,,\3. 192' _21002 STATE OF IOWA' Criminal History Record Check Request Form MW orFax completed forms to: DCI Account Number: 9967-F (iffinlimble) - Send roaulte to: Iowa Division of Crikainal Investigation Name Yellow Cab of Iowa City Fmx[ams�Trep�-1"�7ea1' 215 E. 7Q b lxeet Address P.O. Boz 428 , Des Moline, Iowa 50329 (515) 725.6066 Iowa City, Iowa 52244 (51.5) 725-6080 Pax Phone 319 338-9777 Har 319-359142 .copy>:,end M Op,` qr As of `9,-� Cti//ar,:. ,.....:. o a search of the rovided ndtu F — P e al'L78� t)gbfllh;lLVC810d O D No Iowa Criminal History Record found with '; �x i,�..�,41 rc int? i?;;. 71 ❑ Iowa Criminal History Record attached, DCI z o ," fir•... ••...• �Ir,;4 �.. DClinitials %;�ktiia., V rr 90 'p of DCI -77 (updated 06-26-2018) ' Page 1 oft Received Time Dec. 10. 2019 9:46AM No. 1355 Dec.13.2019 10:16AM DCl IOWA No. 1921 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 confidentlai juvenile records, if any, an application must be filed pursuant to Iowa Code section 232.147(f8). Additionally, criminal history data concerning convictions for certain juvenile sex hftn:11www.10wasexoffender. coml. 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 confidentlai juvenile records, if any, an application must be filed pursuant to Iowa Code section 232.147(18). 0 O '4 �-! A DOT SMARTER I SIMPLER I CUSTOMER DRIVEN w^"^' iowadot goy orMM & WentilkaWn E4tvicss PO Box 92041 Des Moines. IA 50306-M Phone- 515-244-91241 Fax 515299- 1837 Certified Abstract of Driving Record Inquiry Date: 12/10/2019 DL/ID #: 769YY3726(IA) Customer #: 677799 Name: Koedam, Jeremy Class: D IO Status: None Jonas Sign/Signal 07/01/2019 07/16/2019 Address: 518 NICHOLS AVE Audit #: 1542972 DL Status: VAL Under Control Issue Date: 01/11/2017 CDL Status: None City/State: NICHOLS IA Expiration Date: 04/30/2021 CDL Cert Status: None 5276677f1 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: PO BOX 93 Restrictions: NONE Restriction None Supplement: Date of Birth: 04/30/1982 Mailing NICHOLS, IA Sex: M City/State: 527660093 ry 0 History Information c'i Convictions ry =1 c'> -.I r —�r— Citation Date Conviction Date ACD Explanation CountyR x 07/16/2017 08/03/2017 M14 Fail to Obey Traffic Johnson �, IA y Sign/Signal 07/01/2019 07/16/2019 D72 Fail to Have Vehicle Johnson IA Under Control Name: Koedam, Jeremy Jonas DL/ID: 769YY3726 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: 12/10/2019 Name: Koedam, Jeremy Jonas DL/ID: 769YY3726 Driver & Identification Services Iowa Department of Transporation N D I C-) PQ r m o w