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Home My WebLink About20-017I l 1 ®4 llpkMIM®�� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) _ IDENTIFICATION NO. L0 — 0 t 7 (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 2. Address (REQUIRED) P11.1- 3. Contact Information (REQUIRED) Email: 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa /F�irst Middle / VJGry (."j.It A„e.. wee 12 (L��jev I T -A Stz2-1- featke,w e.fi,nstifi Cell Phone: %4( SqI O&1'1`[ iritten communication sent via emaill min 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Iz Where When ---I t CI) What happened to the charge? (Circle one) c Convicted Dismissed Deterred SuspendedadGuifty herd_ 7. Have you been arrested / charged with any traffic offenses in the last live years? h;1 Tvpe of offense Where What happened to the charge? (Circle one) Convicted Dismissed Deferred When Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Ino 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 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 her�y certify that 1 have issued to me by the Iowa D a m nt of Transportatio a alid Driver's license number (O S 7-7- qi issued on expiring on 1 b 1 understand that if I falsely answer any questions in this application, that this applicati n may be denied. I agree ilhat 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 provisio of Title 5, Chapter 2, of the City Code. (Needs to be at7f, d in front of a Notary Public) A Signature of pplicant Date Z ZO aaaaaea+aaareaaa++aaaaar+++aa+raagar++a+++++arr+rr+rr++rr+rr+++r+rr++arr+arrrr+rrr+arrrrraarerraaaaraaaaara»»a•aaaeaaaaaraaa+aaaaaaaaraaararaa STATE OF IOWA ) COUNTY OF JOHNSON ) S bscribed and sworn to before me by &a ri 0 . VACLS [ on this �7L-P day of VWNDY S. MAY_k Notary Public in •r++rr+r.w++r+r.+r+++rr++rrea+rre++r+rr+++e+rrrr++rr+r+,+�+++r+r++rw+++rr+++++e++r+r+++++r++++»++++»+aa+a+e+++a+++++++++,(�+++++++++++++»++ I have reviewed this application, DCI report, and the State certified driving record of this applicant aedfibve;gtermined that there is no information which would indicate that the issuance would be detrimental to the safety, h"-ltttror mHare of'resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). — M Q) 'ern m M Expiration to Dri s license (J %- 3 20) Z 3 '.0 I _07 Signal W f Police Chief or designee 07� Z G- zm7�o 0 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 "Z� -Zd Date Cb,r✓rnxioaivenoceavn9201eaffe,md.DOC 04/2018 Fro.l eU, 2�. 2020. 8: 20AMciolk )bl IOWA 310 3596497 02H8/2020 011:6No. 1598167 P. 1/2/002 STATE OF IOWA _ ,,, Criminal History Record Check a Request Form is 4 IF I put Mail a Fax completed forms to: Iowa Division of Criminal Investigation Support Operations Bureeu,14 Floor 7,15 E. 711% Street Des Moines, Iowa 50319 (515)725.6066 (515)725.4080 Fax I am reauestine an Iowa Criminal History Record Check on: DCI Account Number: , 4 o b , F (if oppliogble) Send results to: Name I I �u h� 1 oula Ci �u t situ ocy 5 e � Address N to C. wa%v r%L Aen St. 1 awl a G Ima . l A s22zt� Phone 31a -0696 -soy, e Fax 319- Sf b- 5491 7 Last Name (mandatory) :.' . ' First Name (mandakry) Middle Name :e6mme deal) h 11L;4v-,;; Date of Birth (mandatory) Gender (ma -"Ory) Social Security Number (nim mended) 25Male ❑Female L{ 3 -% 0 (0 67 Release Authorkadon: Without it signed release from the subject of the request, a complete criminal history record may • :, not be releasable, per Code of Iowa, Chapter 692.2, For cmuliate criminal history record information, as allowed by law, always ob(alp a signed release hom the subject of the request ::.' `***This form CI- is the out a roved release authorization form for this ur ose *** Release Authorl2adon: I bamby sive pomiwast for the above mquening offudd to aoaduct an lawn criminal history na:otd cbeck with the Dfvfsioa of Criminal Investigation (DM). Any eriminal history data concerning me that is maintained by Nb PCI tnay d!7 46 a1loWod by 4w. 1 Upderstaad this nn inelpda . information cpn(vuing mmpkwd dcfc*mpluAitneora �M artc wiMt?ul dieposidona. Release Authorization Signature: Iowa Urindnal History Kecord Uheck Results Fie ! 1 IIID As of a search of the provided name and date of,birtii revbalpI Ile 3) No Iowa Criminal History Record found with DCI a/ Crib ❑ Iowa Criminal History Record attached, DCI # DCl mitialfc t�n .Se ct1 of , DCI -77 (updated 06-26-2018) Received Time Feb, 19. 2020 8:08AM No, 0711 (DCt use' Zo ? 3 N a O a, Z k,.y 4 O m rr W W U Page 1 of 2 heb.15.2010 6:21AM UGI IOWA No.1598 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 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.lAvww.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 0 N U ww o n ..,� r- rn sm rn a y, 0 A4WWADOT SMARTER I SIMPLER 1 CUSTOMER DRIVER www'I[l,nradt]t gy DrKW & IdeMillkagori SMIONS PO Bax 9264 I Des Wine& IA 53306426/ Phone 515-744-9124 Fax 511-M F837 Certified Abstract of Driving Record Inquiry Date: 2/18/2020 DL/ID #: 965ZZ3973(IA) Name: Maske, Gary William Class: C Address: 2922 C Ave Audit #: 2635566 CDL Med Status-' Issue Date: 03/15/2018 City/State: Deep River, IA Expiration Date: 07/31/2023 522228011 Endorsements: NONE Mailing Address: 2922 C Ave Restrictions: NONE Date of Birth: 07/31/1953 Mailing Deep River, IA Sex: M City/State: 522228011 History Information Customer #: 3269414 ID Status: None DL Status: VAL CDL Status: None,-, CDL Cert Status: None ]; CDL Med Status-' Restriction-,,..Non�- Supplement: - Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number 3UR 06/20/2016 932708 IA Name: Maske, Gary William DL/ID: 965ZZ3973 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: 2/18/2020 Aazle�O Driver & Identification Services