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Home My WebLink About20-018CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) _ IDENTIFICATION NO. 20' o 18 (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 Z First Middle CISj /A/ L_ Nus G F: -,sr 4 SZ29U 3. Contact Information (REQUIRED) Email: w _7 `J ICeII Phone:( 3r��=�/ "-7I $u (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) '),/ --2 0-1 5 b. Taxicab Business Name (REQUIRED) na') �'th 5. Prior experience in transportation of passengers: ri t ,e i 6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State ;ot etsevqg)re?y o Type of offense Where gn co 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? Type of offense Where When 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? h U 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) PAGE FOR r Kub 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 De art ent of Transportatio a valid Driver's license number 4-? A['`.3-7 h issued on xpiring on .L p 07� 1 understand that if I falsely answer any questions in this application, that this app cati n may be denied. I a ree hat 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, C apter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicantl__�___ Date a July 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). -30- z07,� ez- zF- Ga7,2. 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. Date Office Use Only Approved application DCI report State certified driving record Website update 0eWTAXIDRNflADGEAPPL9201Samended.DOC 04/2018 ..+,_+_+.._...«......:.>.,_«,,,,..._...+....,. »....,,.,,, ......................t...........,.,.,+..............++.. fie;..«.+..-.....,...,,..» STATE OF IOWA ) COUNTY OF JOHNSON ) r Subscribed and sworn to before me b r Y i �� e q �v\ k oa this C�0 29day of F 0. n Gr— ASHLEYAJAY-PLATZ � A r mrt cAion No. 785030 Notary Public in an tate of a July 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). -30- z07,� ez- zF- Ga7,2. 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. Date Office Use Only Approved application DCI report State certified driving record Website update 0eWTAXIDRNflADGEAPPL9201Samended.DOC 04/2018 o2Lb. 24. 202 j0.11:44AMCob e I DCI IOWA 4;AM193382,No.1413 P. 1/51004 STATE OF IOWA Crimfinal History Record Check Request Form I Iowa Division of Cr6uimi Investigation support operations Bureau, in Floor 118 B. 71b Street Des Moines, Iowa $0319 (515) 723-6066 (515) 725-Q080 Fax ACT Account Number: 9967-F (if W11cable) Name Xe11dw,c* of Iowa City Address P.O: Box 428 Iowa CRY, Iowa 52244 Phone 19 8-9777 Fax 319.959-4142 on: co e/6s gP ,?EiFaLfi7iilfjj± rEeot!9 may irauSN6gc:i'llb4retl:b j•IswT wgiy'�,� rpyyiy{b¢�.Wid1�C'f�10{SiOa Of ' ?:i{:!�o`4e3.6Ylea'; f mdery�adlala ran include liyLnniY.r..;x, As of FEB 1 I 2= --- a search of the Provided name and *WINO Iowa Ctimitwl ITIstaq Recofd found with DQ ❑ Sect+'' Iowa CfiminaT fTistnry Record attached, DCT # DCI initials— (r DCT -77 (updated 06-26-2018) Received Time Feb. 18. 2020 1:05PIA No. 0575 Page 1 oft • Feb. 24.2020...11:45AM DCI IDWA No 1413 P. 2/5, ffW193i82.� ._..J004 STATE OF IOWA Criminal History Record Check Request Form r Mail or Tan mdn la ed ��ne r ; Iowa DIVIdou of Criminal Inveogation support operations13mma,1•Floor 213 X r %T& Dos Mojave, Iona 50519 (515)725.6066 (915)725-6080 Fax . '3 ka�- 3d /l ,74X DC[ Aacouat Nwnber: 9967-F (ifappue") B�rveiilt+to: Name _-YelldwCGae of Iowa Gil Address P.O. Box 4ZB _Iowa City, Iowa 52244 Phone 19 8-9 Fax - 319 Sd9 41'42 :male Cf �f PG7 ,. - :.: �`3� �a➢1'?Y;{i�}:y'rixorilmay �kPtToeT6o�tcbnFecY �.�jM �yp�q! W31v'OeDivitiao of y`�•'c: j IFr "•'r'I:�I° '49 49lydv.� ueda14�d.d k mn illh* " corct Wleckesu is As of FEB 9 d 2RZ7 arch of the /51 a seole q provided name and date of bid pl �o Iowa (lumna] history R.vocrd found with DCI Ltt ❑ Iowa Criminal History kword attacbod, I)Ci # " "n ...... nmaa DClinidalo DCI -77 (Updated 0626.201 B)' Received Time Feb, 18, 2020 1:05PM No.0575 m Page I of 2 �jFeb.24.2020...11:46AM� DCl IOWA r � �... . I As of fA)p81Y 9X ZN o. 1413 r,. 'STATE OF IOWA Criminal History Record Check Request Form M&il or Fax completed forms to: 10wa Division of Crhglnal Tnvestigation Support Oporatfou Bureau, l"Irloor 215 X 70 9troot Du Moines, Iowa 50319 (515) 725-6066 (515) 725_6080 Fax w FEB e e 1w P. 3/5w DCl Account Number: 9967-1z (ltwumble) Send results to - Name yeD&Gao orlowa 3ty` - Address P.0.809418 I--, Phone 33 77 T PBX 319.359:4142 ---------------- a search of the provided name and dato g C' ,_. waGso6mrm dwd YSI �?Y?W7 & ,. . � , : •eY�ilhe�ory'r4eok+fi may its mdF1a vn � k, lfbPoe�ISivision of ,�'$'��°,� i8.fe�v;�macrerc�e.mL c� incluE6 "fi1 a •g.•7• r. r . Iowa Criminal Histpry Record found with DCI U •. ❑ 1 Iowa Criminal Matory Record attached, DCI # ''rrr Eton .F DClluidale c� DCI -77 (updated 0626-2018) Received Time Feb. le. 2020 1:05PM No, 0575 Page I oft „4 DO SMARTER 1 SIMPLER I CUSTOMER i)R�' B � fDU1t�C�O� C�CaU Drivel & Idii Wification Smites PO Ecx T-4li I Des tmnes A 503MI92W Plane515-244-9124 1 Fax 51 L-239.1897 r� Certified Abstract of Driving Record «. -n i w a Inquiry Date: 2/18/2020 DL/ID #: 153AC8715 (IA) Customer #: c- r`47*77 Name: Fultz, Kristin Lee Class: A ID Status: r=None Ann •_ ;-n f mss._ Address: 328 Nightingale Or Audit #: 2401598 DL Status: Issue Date: 12/19/2017 CDL Status:ELG-- 0 City/State: Tiffin, IA 523409437 Expiration Date: 12/30/2025 CDL Cert Status: None - Endorsements: Tank, Double/Triple CDL Med Status: None Trailers Mailing Address: 328 Nightingale Dr Restrictions: Corrective Lenses Restriction None Supplement: Date of Birth: 12/30/1965 Mailing Tiffin, IA 523409437 Sex: F City/State: CDL Medical Examiner's Certificate CertificateSpecifics Explanations Type Downgrade DowngradeStartDate 08/26/2018 Issuing5tateCode IA History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date I Case Number ]UR 07/21/2015 869741 IA Name: Fultz, Kristin Lee Ann DL/ID: 153AC8715 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: Name: Fultz, Kristin Lee Ann DL/ID: 153AC8715 2/18/2020 (7— Driver & Identification Services Iowa Department of Transporation 0 N A q M_` CO q 7� > CD