HomeMy WebLinkAbout20-042� r 1
CITY OF IOWA CITY
410 East Washington Street
Iorca City. 10X•2 52240-1826
1319)156-5040
(319) 156-5497 FAX
IDENTIFICATION NO. 20-01l
(office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAS VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
FaNure to complete the "required" Information will result in denial of the application
Last
First
Middle
1. Name(REQUIRED) La5Gc.0w3;kI jasa,pL, Wales✓
2. Address (REQUIRED) SiXr WAIJI- F -S%. Tat. t.C� fy� M-14 S -.2.7 -yo
3. Contact Information (REQUIRED) Email:i wi O S4�I tp (ra��y� a✓0,-44 Cell Phone: 3/J* -69/,.2709'
`(All wntten communication sent via email)
4a. Driver's License expiration date (REQUIRED)_ OSl , Z.S . 7,dZ9- �2-��7!;L) \
b. Taxicab Business Name (REQUIRED) W'6M'i 6„ 4P o --jr.' X J
5. Prior experience in transportation of passengers: �i5 .1 y�i_ ✓s }{r y lGjz yy,:j e
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? tia
Type of offense
Where
When
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? /LQ . ;
Tvoe of offense
What happened to the charge? (Circle one)
When -
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 year;? _ tiV
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)
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
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 certifythat I have Issued to me by the Iowa Department of Transportation a valid Driver's license number
---y�� 2 Issued on q, 2/..2oi0 expiring on Y 2S Z#o Z� I understand that if I
falsey 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)
(rrfl
Signature of ApplicantDate /4 •7, 702,
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this -> day of
Notary Public In and for the State of Iowa
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 real,
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Driver's license 6y' ZS-' 2-3
Slgnat f P Ilce Chief or designee
Id W, 2-0
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.
7et,„�tk ,e>cp,res
Slgnel re of City Clerk or slgnee 10 Date
*4th*ftY4Yf#YNfRtf#f4tR%f:hlX#fit#4XitifftR1i4f4iMR4RA##k4it14XR%%1XXYi#XXYR%%tX4fiif k##%Y##Y#*#M#RY#########R4R#HRYt%#4###R######iR*#4Hf#H##
Approved application Office Use Only
DCI report
State certified driving record
Webelte update
CWk(T 1DRNWQ9AM02D18snmd#d.DOC 0412018
Q10WA00T www.iowadot
gov
SMARTER I SIMPLER I CUSTOMER DRIVEN
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PMM:515,W,141241 FSK: 0154WIWY
Certified Abstract of Driving Record
Inquiry Date: 10/2/2020 DL/ID #: 127AC8472 (IA) Customer #: 5231945
Name: Laskowski, Joseph Class: D ID Status: None
Walter
Address: 836 WALNUT ST Audit #: 1761773 DL Status: VAL
Issue Date: 04/21/2017 CDL Status: None
City/State: IOWA CITY, IA Expiration Date: 04/25/2025 CDL Cert Status: None
522403340
Mailing Address: 836 WALNUT ST
Mailing IOWA CITY, IA
City/State: 522403340
Endorsements:
Restrictions:
Date of Birth:
Sex:
Chauffeur 3
NONE
04/25/1973
M
History Information
CLEAR DRIVING RECORD
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
CDL Med Status:
Restriction
Supplement:
None
None
O
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00
0
Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identi0cation 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:
100.1 SNI of rq� 10/2/2020
Qtr"
Driver & Identification Services
Iowa Department of Transporatlon
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
STATE OF IOWA
Criminal History Record Check
t Request Forms
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(515) 7256666
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Iowa Criminal gtsto -Recon 1 Cheek Resie &
As ofa aeerch of the provided napes and date of birth revealed:
* No Iowa Criminal Mstory Record found with
Iowa Crmunal history Record am,
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DQ-77 (npdatsd 06-26-2011)
Received Time Oct. 2. 2020 3:12PM No -7743
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