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CITY OF IOWA CITY
110 Easl Washinglon Shed
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name(REQUIREDI _
IDENTIFICATION NO. a 0O
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 pm., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
Last First Middle
1 ei.S kv, Gc,.y kii 1 tsar..
2. Address (REQUIRED) 7-9 L1 -
3.
t3. Contact Information (REQLI1RED)Email: O�m,kcka@hefinc.Kat- Cell Phone: ``fl Sift 6)32o
(All written communication sent via email)
4a. Driver's License expiration data (REQUIRED) —1( 3t 12,
—�A S-Litti
b. Taxicab Business Name ;REQUIRED)
5. Prior experience in transportation of pas
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? IK O
Tvce of offense
What happened to the charge? (Circle one)
Where
When
FEB 0 9 2021
iowd c,� y, icwa
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested /charged with any traffic offenses in the last five years? hr)
Type of offense
What happened to the charge? (Circle one)
Where
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 years? h 0
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)
SIGNATURE AND
0412018
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 Peplartment of Transporttion a valid Driver's license number
61 (6 S ZZ :9 -73 issued on 31 K I I k expiring on 1 1 -111 .L3—. 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,
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 1Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Z W "4/ Date 3
1111fIN111111NHNNfY1N11N1N1N1NYNN1NkNNNNM1N1Y1NNI11NNf11Y1YNNNNINNINYf YNIN1NNNiN1NYiYYY1111f1f 1ff 1f f f Nf 1f f
STATE OF IOWA )
COUNTY OF JOHNSON ) t�v a� } d F I L E L)
Subscribed and swom to before me by Vv ��� � on this D day of
FEB 3202t-
otary Public in and for the State of Iowa
, Iowa
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).
Expiration date of Drivel's license O7.3 )'L�
Signa ure of Police Chief or designee 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
QZ—I O -21
Date
Ckr000RIVSADGEAPP192018 *.Ided.00C 0412018
krwyz if a w c• —
'STATE OF IOWA
Cominal.HWtory Record Check
Request Form
X?L4r�] 'ax com�IMd f� o=s to
Iowa DivWon of Chnj A Inveafi U,,,
"'o' oPaations Bwvz% In Floor
ZyS 8.7' Street
Des buhm, Iowa 503I9 .
(515) -12 �b 66
(515) 725-q p Fax
DCI Accoot N=ber: 9967
(fapplirable)
d to;
Koine YeIldre oflowa
Address P.O. $ox 428
Iowa CRY, Iovia 52244
Phone 3 ysgy
Fax
319359 4I4Z
FE%U'J `-- : Pagetof2
• C\e�k
—Received lime Feb. 2. 2021 2:061M Ne. 2825 Girl \ovvO
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wa
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SIJARTER 1 SIMPLER I 05TOMER DRIVEf; ww'N 1owad13t.gQv
Ofivaf & Iderad6tatlon 4:arvicas
PO fox 920:1 Des Mcines, IA 6T" 9204
Phcne 545-234-91941Fax 515.299-18.87
Certified Abstract of Driving Record
Inquiry Date: 2/2/2021 DL/ID #: 965ZZ3973 (IA) Customer M 3269414
Name: Maske, Gary William Class: C ID Status: None
Address: 2922 C Ave Audit M 2635566 DL Status: VAL
Issue Date: 03/15/2018 CDL Status: None
City/State: Deep River, IA Expiration Date: 07/31/2023 CDL Cert Status: None
522228011
Endorsements: NONE CDL Med Status: None
Mailing Address: 2922 C Ave Restrictions: NONE Restriction None
Supplement:
Date of Birth: 07/31/1953
Halling Deep River, IA Sex: M
City/State: 522228011
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
I Case Number
JUR
106/20/2016
932708
9
IA lull
C'ty Iolowa
lows City,
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:
Z r<*-�' •.��. 2/2/2021
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Driver &Identification Services