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Home My WebLink About20-013� r A...®oQ �III��t1 C1� F IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED 3. Contact Information (ktUUIKtU) Email: "Ill ' `1 ' C� Cv ' '.ell Phone: S(6, -RUS - V Sgi' (AII written communicatio s nt via email) IDENTIFICATION NO. _ao - (D 13 (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 4a. Driver's License expiration date (REQUIRED) 0612-712-01-t b. Taxicab Business Name (REQUIRED) — P 1 5. Prior experience in transportation of passengers: ti 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? IJ O Type of offense W he Ahen IU 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? What happened to the charge? (Circle one) onvicte 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? 11j() 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) NOT 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 valid Driver's license number ( S S � q { issued on 21t?(294 Dexpiring on alz-712 0)- 1 . I understand that if 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, 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 -Q (��,Date z 112- ( Z. O 2-0 STATE OF IOWA ) COUNTY OF JOHNSON ) 11 11 Subscribed and sworn to before me by f•t Eyam," ) J6 on this 12day of Commission No. 785030 ( ( July 14, 2020 ' - ----- I have reviewed this application, DCI report, and the State certified driving record of this applicant and have oNwdetermined that there is no information which would indicate that the issuance would be detrimental to the safety, health e determined of resi- rm dents of the City of Iowa City (Title 5, Chapter 2, City Code). - : — Expiration date of-brjyefs license -47 or designee N 07-- It 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. of Citv Clerk or Approved application DCI report State certified driving record Website update Office Use Only Date Ge,araxiDRivaADGE PPL92018a�,ded.DOC 04/2018 a is STATE OF IOWA Criminal History Record Check Request Form Mail or Fax completed fo= to: Iowa Division of Criminal Inveatipation Support Operations Bureau, 1°` Floor 215 E. Te Street i)es Moinei, Iowa 50319 (515) 725-6066 (51st 725-6080 Fax I am reauestine an Iowa Criminal Histnry Record Check on: DCI Account Number: 9967-F Ofappb"ble Send results to: Name Xeu& Cab of Iowa City Address P:O. Box 428 Phoue Fax Iowa City, Iowa 52244 19 3381777 319.359.4142 �7 6 , a eowh of the providod'� iQ.and d0ta of birth revealed: As of �' d� STATE OF I No Iowa Ctimlatl HietolYR Ord found 'With L?CI 0 Iowa Criminal History Record attaoht; Da WWII DCI -77 (updated 06-26-2018) Rece ved Time Feb. 4. 2020 3:06PM No, W5 FES 0 5 ZD20 DIV OF CRIMINAL I Page 1 oft roti mil0itl . 5k.i �X 3 �zn ` IGtit. ❑Male emate 4"79 -qZ I — S -SL Y� �'' w;;jW Y, M1M1��Ijj"I:F�IlJL�yt}IW-f • .. ' . :� aW ._ . _. r � 3�ic..=tq:�s•t..r .o.c.... � ��.-i; a.+.. *mss>uT- s „�.:.. :Mx � �il �Mx�sF`o r.,� `lY IG w�1SStl1ei)fvlWon ae ��Tim,m'� a4ip' I tin a`i' ;may l o��r vndbnb�ddl}dsanlnoleds _��:o �7 6 , a eowh of the providod'� iQ.and d0ta of birth revealed: As of �' d� STATE OF I No Iowa Ctimlatl HietolYR Ord found 'With L?CI 0 Iowa Criminal History Record attaoht; Da WWII DCI -77 (updated 06-26-2018) Rece ved Time Feb. 4. 2020 3:06PM No, W5 FES 0 5 ZD20 DIV OF CRIMINAL I Page 1 oft DISCLAIMER This response can only include public criminal history data. Under Iowa law, most Juvenile records are confidential. Confldentiai 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.iowasexoffender 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 confidential juvenile records, If any, an application must be filed pursuant to Iowa Code section 232.147(18). N d N rri v C-) DC7 N �r M -v i N r O'c"1441ultivADOT +,;t1`1An4''1.1 OV'Jadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEL. _ _,—_ Driver & Identflieation services PQ Box 9204 Des t.1clnE- IA fro; 0&Y20A Pt,cne 515-711-9124IFax 51=2439-1837 Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 2/5/2020 DL/ID #: 153CC5039(IA) Customer #: 4557131 Name: Jaworowskl, Class: C ID Status: None Si n Si nal Alexandra Hope Address: 1655 N. Jones Blvd. Audit #: 9787431 DL Status: VAL Apt.8 Issue Date: 02/17/2016 CDL Status: None City/State: North Liberty, IA Expiration Date: 03/27/2021 CDL Cert Status: None 52317 Endorsements: NONE CDL Med Status: None Mailing Address: 1655 N. Jones Blvd. Restrictions: Corrective Lenses Restriction None Supplement: Apt. 8 Date of Birth: 03/27/1992 Mailing North Liberty, IA Sex: F City/State: 52317 History Information Convictions Citation Date Conviction Date ACD Explanation lCounty 3U 05/03/2019 07/09/2019 M14 Fail to Obey Traffic Johnson GJ IA N Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa Department of'Transportation, Si n Si nal 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: r 2/5/2020 c n,ikmr A TAnntifiratinn Cundro< n—G N Name: Jaworowski, Alexandra Hope DL/ID:-'153CC5039 N 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: r 2/5/2020 c n,ikmr A TAnntifiratinn Cundro< yi l..ED 2020 FEB 12 P l 1: 24 CITY CLERK 10!';`\ CITY, MIA M 0 U U M N '1 M J Q