HomeMy WebLinkAbout21-023IDENTIFICATION NO. 4, ( — 0c;3
(Office Use Only)
APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF O WA CITY (Police Department r l(eey {p}tlVe Prdl05 een s a.m. to 3 p.m., Monday — Friday)
410 East Washington Street :=allure to complete thell"re::lfyec4' "r �afion w%O esul(in denial of the apniica._:;;.
lona Cite, lana 52240. 1826 IO+txr l [,iTY Ikt1F��
(319) 356-5040 Last First Middle
1319) 356-5497 FAX
1. Name !Pc7Ui.',E 1 �,/rS`tn;.ySb1n �Ir's�Aln tV(A /4i ,-
2. Address Cr I-X 7 -'ZZ y O
3. Contact Information (REQUIRED) Email: 1 W j t/J5-k-J4,04lt 'd -ZQtw, Cell Phone: 3/9 sYY,a?U 3'
Ali written communication sent via email)
4a. Driver's License expiration date (ECUI?D; L' c/- ZS- ZOZ 5� 1 Z -7-4L W % 2-
b.
b. Taxicab Business Name (RECUT=D;. Lkl(ow (-"b c �- rc: w Cr i y
5. Prior experience in transportation of passengers: "ter Lit
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? 410
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? n&
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? AA)
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 narne(s)
.4 u
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0412018
Page 2
APPLICATION POrtTAXICAtd VEHICLE DRIVERCeRt'Fluo
ICAATION
DEPARTMENT OF CRIMINAL INVESTIGATION (I LT16N FOR POLICE CHIEF REVIEW
MCI O+�E
DRIVING RECORD MUST ACCOMPANY THIS APP
L
You must apply for an individual Department of Criminal Inve®tigattop Report (form available upon request).
I hereby certify that I have issued to me by the Iowa Department of Transportation as valid Driver's understand number
I
r /?Z Issued on D ✓ 2I i7 expiring ie U�
falsely answer any questions In this application, that this application maybe denied. I agree that in making this aecordtlon, l
consent to allow agents or eine any
mpaof ndthfurther Of Iowa agree that, aouthorization owa, In their f beeait xicab don, to rirlvler is granted, to comply ail
documents relating to this application,
times with all of the provisions . f Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public
Date dy.�`/
Signature of Applicant_ — -- — —`
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by
on this � day of
crdthis applicant
oat
Ihave
reviewed
this
a Dree ssuane wouldbe etrrimental tothe afety, health r welfare of rest -
h re is r which would Indicate hat th
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Driver's license
'-/����
2 Z /
Sig a ure of police h of or designee pate
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THEPATE LISTED BELOW.
Office Use Only
Approved application
DCI report
State certified driving record
Wobsite update
y I 2—,L%2�
ate
0WAXIoRNBAAOEAPPL07.01Bemanded,DOO 042018
Apr, 14.2D21 10:30AM DCI IOWA
0/112/2021 15:57 Yellow Cob
TAM193382700 P.0021002
I
`�i�li6Ut1 ,
7021 APR 19 PM 1:43 i r
STATE OF IOWA •-
Criminal History.. Record _Checkis
Request Form
Ml AccnurtNumber:
_. (iraptdwable)
TO: low& Division of Criminallnvestiliatton From: EGU Gal of -Tl(A.ta G, y
Support Operations Bateau, 1" Floor 20X (42E215 1.7'k Street rp O
Dos Moines, Iowa $0319
(515)725-6066 _Tower L;{j rat -h- 522yy
(515) 725-6080 Fax
Phone; 30- 33`x97[�
' 77
Fax: 317- 359- 7 % IU
.2
I am reauestinst an Iowa Criminal Hisuuy Record Check on:
Lest Name Onand First :Mame (mardwry)
Middle Naaue (rawmaaw&d)
LASIGac✓5`C.Z"
JastP}1
W��rr�.
Date of $firth ,,Tabun
Geader (ma Wa )
SocW Security Number ecomayeamd
0Y Zs- 973
®'Male O]Feaele
I /(r8 'SZ_-TSZ7
Waiver Information. Without a sipbed waiver from the subject of the request, a complete n Iminal history record may cot
be releasable, per Code of lows, Chapter 6922. For complete criminal history record information, as allowed by levy, &Maya
obtaia a waiver sign&tare from the Dublaev of the request.
Wanter Re%6C: 1 hereby gine ;ermi .m ford= abo> o raquaadng aAiiat to oon:oot an Iowa aamrul h story m-ro d Omk waft the Das M CrYohti
laaer6pdm (DO). Any aimiral bmwy dan c000amirg tea *Ar a matntalnsd by the DCI may be releamd a allowed by low,
— Waiver Signature.V�+�/
— —
Iowa Criminal History Record Check Results
V,
L{ a search of the
As name dare birth
of provided and of
revealed:
X
No Iowa Criminal History Record found with DCI
Ort" Y
9 :i
O Iowa Criminal History Record attached, DCI 9
V,r
mt
DCI initials
,,,,+•'aL
DCI -77 (08.125/10)
0...;...,A 1;-,. A.. to IAnI 0.7GFu W. 1101
C491 OWA D DT ,Nww iowadot. ov
SMARTER I SIMPLER I CUSTOMER DRIVEN g
Drir« 8IfiffA isation SsrvieeS
PC Box 9201 I Des Manes- IA 5030&S2M
Pilon 515-244-91241 Fax 515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 4/16/2021 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
Endorsements: Chauffeur 3 CDL Med Status: None
Mailing Address: 836 WALNUT ST Restrictions: NONE Restriction None
Supplement:
Date of Birth: 04/25/1973
Mailing IOWA CITY, IA Sex: M
Clty/State: 522403340
History Information
CLEAR DRIVING RECORD
Name: Laskowski, Joseph Walter DL/ID: 127AC8472
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: Laskowski, Joseph Walter DL/ID: 127AC8472
4/16/2021
A2Z2ebL
Driver & Identification Services
Iowa Department of Transporation