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Home My WebLink About21-035� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIR 2. Address (REQU 3. Contact Information (REQUIRED) Email:,'�r ^14er—Eq *=d= -Z p Cell Phone: 3/9'—is soSU'7e& (All written communication sent via email) IDENTIFICATION NO. 21 .d-?�s (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 aoolication Last First Middle 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) T 5. Prior experience in transportation of passengers: -294 - of 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,, ll 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? NQ 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 04/2018 N r ya, What happened to the charge? (Circle one) i Convicted Dismissed Deferred Suspended Plead Guilty '.Oilier !a 7. Have you been arrested / charged with any traffic offenses in the last five years? 140.5 Type of+off-ense Where When 'IP cdai 461y� ca� n w Vida 1 " CIm, -TRfXir— Sen -A( k CaLknLI What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other,, ll 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? NQ 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 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 hereb certify that I have issued to me by the Iowa epa ment of Transportation a valid Driver's license number 4ek A �feS�E issued on expiring on 112!f 4019. 1 understand that if I falsely answer any questions in this application, that this applica ion may be denied. I gred 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 ggwted, 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 afflotary Public) C- -7 , _ Signature of Applicant Date' -. N �. _ r STATE OF IOWA ) v COUNTY OF JOHNSON 1 and sworn to before me by on this 20 day of 2 L...- ASHLEY A JAY-PLATZ Commission No. 785030 Notary Public nwr m Jul^—r 14 ##*N#4kN#N**t####*#fN1Mf#+F#R1t1t1t#1t1t1tNRltfffNN##f1t*ftf1NNN44#*#f4#*##R*##NNltfefe left*#**#*k*#t#**#####1#N#N**##1;�1t#*fefeN*INN�!#1iRRRN**N 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). Expiration date of Driver's license 2Z? v LZv 2 If Sigirfature of Poli e Chief or designee — -412012021 T� 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. of Citv Cteki(or Approved application DCI report State certified driving record Website update Oeh/ MDRN ADGEAWL92018am nd .DOC Office Use Only 12-1 21 D to 0412018 07iJu1:14.202IS: 10:OOA4 Cob DCI IOWA fA=93MNo_4909 P. 1D02 Z STATE OF IOWA Criminal History Record Check Request Form 4W 2 Division of Criminal Investigation ort Operations Bureau, P Floor ;. 70 Street .follies, Powe 90319 725-6066 725.6080 Fax I am reouektin¢ an Iowa Criminal History Record Check on: Da AcconatNumber: 9967-F (ifapplicablo) Seed results to: Ivama Yeldw4eb of IM Qk 0 Address P.O.Ifo:42111 O ti t— lows Unlows 32214 m -..- P. •-.•� Phone 1 3$ r pop FU 319.3594143 Z v AA"AAAaA XAADa.VA'r .RGVVa•s l•.AAOVA I\"UILO (DC1` Oetj') As of — 4 a eesreh of the provided Hama and date of • ,.- ��OWA/DPS , t9F o Iowa Criminal History Record found with DCI~ Ul .`3` 021 ,I • Iowa crimi al : s• `g hb gk)ut 11u111 INVEST Iowa Criminal History Record attached, ICI # F DCI initiais�r�n.r"'"• • Sic DCI -77 (%Asftd 06-26-201 g) •; Pala I of 2 i Received Time M.12. 2021 3:27PM No -4623 �i Ga�E .y. •u �...� ..1a.:y-Atl'i�.�-,. �:�f 1 � • t �....M'�i:.[�himw�e� Z. � �E -- 19 male �T+emstia 3Z4'—TD -�� b V. Ir iErl ��ti t! s�6nuFe1, Cp�idmaY to 1feTt sttl` rdfrl'evNt�Iipltlw, o4J. W �.CM.iiv. .! �•4 • +`S .. r`a � )i, r` ��+M U9.,•ti gi''3_ySiXaSe.,'�".t �IPisin4j=i''(iP'%`., ,. ,.. �`` �Y'��5 4§ar♦`�b�in"d ��(laY �'��ia�'�i, �ataod Shheau iocfiido". •.• atd:ni5)o m i' l e A eika( sp'Ssmbvts_, � .i �.M 7; •u� . AA"AAAaA XAADa.VA'r .RGVVa•s l•.AAOVA I\"UILO (DC1` Oetj') As of — 4 a eesreh of the provided Hama and date of • ,.- ��OWA/DPS , t9F o Iowa Criminal History Record found with DCI~ Ul .`3` 021 ,I • Iowa crimi al : s• `g hb gk)ut 11u111 INVEST Iowa Criminal History Record attached, ICI # F DCI initiais�r�n.r"'"• • Sic DCI -77 (%Asftd 06-26-201 g) •; Pala I of 2 i Received Time M.12. 2021 3:27PM No -4623 t% Ju1.14.2021 10:01AM DCI IOWA No.4909 P. 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 concern/ng convictions for certain juvenile sex offenses can be found on the Iowa Sex Offender Registry. htto.I/www.iowasexoflendeccoml. However, even though some information is available on this site, the actual records for juveniles 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). o — �^ C:= �m x.FTI ry c.n fay . C410WADOTwww iowadotov SMARTER I SIMPLER I CUSTOMER DRIVEN g DrNer & 11ftnt Batibn rMbM PO Box 920a I Des Mkline& IA 50306-9201 Phone 515-244-91241 Fax'. 515-259-1837 Certified Abstract of Driving Record Inquiry Date: 7/14/2021 DL/ID #: 492AS4054(IA) Customer #: 7056532 Polk Name: Jeffrey, Scott Allen Class: C ID Status: None Address: 5404 SE 14th St Apt Audit #: 4987769 OL Status: VAL 16 Issue Date: 09/23/2020 CDL Status: None City/State: Des Moines, IA Expiration Date: 02/24/2028 CDL Cert Status: None 503201614 Endorsements: NONE CDL Med Status: �ne Ri Mailing Address: 5404 SE 14th St Apt Restrictions: Corrective Lenses Restriction c- 16 Supplement: Date of Birth: 02/24/1966Mailing Des Des Moines, IA Sex: M --1 C7 r" { City/State: 503201614 ,^*t a }^ry History Information -'0 3 r r 1i N Convictions C^ Citation Date Conviction Date ACD Explanation County ]UR 11/16/2020 02/12/2021 S92 Seed Polk IA 03/18/2021 04/20/2021 M14 Fail to Obey Traffic Sf n Si nal Polk IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 103/18/2021 1231932 IA Name: Jeffrey, Scott Allen DL/ID: 492AS4054 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: nc rq� 7/11/4//22002�221/11� f/t/ Ooe `z Driver & Identification Services Iowa Department of Transporation Name: Jeffrey, Scott Allen DL/ID: 492AS4054 _ ti O DC7 L 0 -�7 r01 + DCD fV