HomeMy WebLinkAbout20-058IDENTIFICATION NO. 20 O S 8
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
CITY OF IOWA CITY
410 East Washington Street Failure to complete the "required" information will result in denial of the application
Iowa City. Iowa 52240.1826
13191 356-5040 Last First
13191356-5497 FAX
1. Name (REQUIRED) &C Wq,'1 �
2. Address (REQUIRED) 5119 iv dic15 Alt
3. Contact Information (REQUIRED) Email: )Cfe,-1 A04�a
4a. Driver's License expiration date (REQU
b. Taxicab Business Name (REQUIRED).
5. Prior experience in transportation of pa
S
sent via
Cell Phone:
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
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?
Type of offense
Where When
-fe;lure 40 - 'rd " 5 -'kA
What happened to the charge? (Circle one) ` `--; c--Cqr�L( U. Ile T74
Convicted Dismissed Deferred Suspended PI d Other
8. Has your driver's license or chauffeur's license been suspended or revoked In the last five years? A)b
Tvoe of offense W here When
9. H veryou 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 here y rt�Y that I have Issued to me by the Iowa epartmeKt of T anspo tign a valid Driver's license number
fit �7rXo Issued on h I' expiring on ref ' Z ( I understand that If 1
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 pro ns TIU 5, Chapter 2, of the City Code. (Needs to be signed In front of a Notary Public)
Signature of Appiican
Date 2 �D+��
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this day of
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Cl
and the
te certified
rd of
licant and have determined
there els no Information matl n ed this which wouulld Indicate that the sssuance wouldbedriving
detrimental tolthe spafety, health or -welfare of rest -that
dents of the City of Iowa City (Title S. Chapter 2, City Code).
Expir date of Driver's license _� 1 LI " Z
/> /a
Signatureof Polic ea gnee bete
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
Webelte update
Date
0 WfAMPA ADOEAPPL420100nnded,D00 04/2018
C4010WADOT wvvwiowadot. ov
SMARTER I SIMPLER 1 CUSTOMER DRIVEN 9
DrWa A Id 3110111 Elrvtaes
PO Box 9201 I Des IAomes, IA 50306 9201
Phone 515-244-91241 Fax 51S23r91697
Certified Abstract of Driving Record
Inquiry Date:
12/15/2020
DL/ID #:
769YY3726 (IA)
Name:
Koedam, Jeremy
Class:
D
CDL Cert Status:
Jonas
CDL Med Status:
None
Address:
518 NICHOLS AVE
Audit #:
1542972
Issue Date:
01/11/2017
City/State:
5NICHOLS 276677E 1A
Expiration Date:
04/30/2021
Endorsements:
Chauffeur 3
Mailing Address:
PO BOX 93
Restrictions:
NONE
Date of Birth:
04/30/1982
Mailing
NICHOLS, IA
Sex:
M
City/State:
527660093
History Information
Convictions
Customer #:
677799
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Sign/Signal
Citation Date
Conviction Date
ACD
Explanation
county7UR
07/16/2017
08/03/2017
M14
Fail to Obey Traffic
Johnson
IA
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:
Name: Koedam, Jeremy Jonas DL/ID: 769YY3726
12/15/2020
Driver & Identification Services
Iowa Department of Transporatlon
15.2R00:.01PI ca DCI IOWA f ��I/
No.7107 P. 2_�ppQ
' 'STATE OF IOWA
Criminal History Record Check
Request Dorm
Mel7_4[�u �1� io:
Iowa Dividon of cridival Tuveadgadon
Support (Vft-attoas Bureau, la Floor
215 L. 7a stry c(
(S725 -0
666M 40319
(315)725-6080 Fax
61
DCI Account Number. 9967-F
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Address
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Phone
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Dec. 15. 2020 12:02PM DCI IOWA No. 7107 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://www.lowasexoffender.com/. However, even though some Information is available
on this site, the actual records for juvenlles 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).
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