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HomeMy WebLinkAbout21-0391 f t lll�■l CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 3 56- 5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. -I\ — 0�6l (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 application Last First Middle 3. Contact Information (REQUIRED) Email: 4a. Drivers License expiration date (REAL b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? NO Tweofoffers e Where When _ w c What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? © YNCG Type of offense U Where When W hat 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? No 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) 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 hereby certifv th t I have issued to me by the Iowa gepqrtment of Transportat n a valid Drivers license number �tr(p 5 Aa Ip 3 nQ issued onO expiring on 1 understand that if I falsely answer any questions in in hi�n, that this application may be denied. I agree t at 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 ans-af Title 51 Ch of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant ( /iS�o, L PDate STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to befor on this �) �J day of ASHLEY A JAY -PLA o � Commission No. IM30 My Commission Expires Notary Public in and or ate o owa i'IIeM#kk*M1'hMM4e1Mk:F1M�1e#�1`1eMMMkfFkf#4#kiiiM1f44#kFkilitl4 M' 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 `!/2 6 / 2 0 2 Sig5dfure of Police Chief or designee ,jr // S12 �— 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. 9Z,:-2) & or signee I Dat Office Use Only Approved application DCI report State certified driving record Website update Qer AXIDRIVMDGEAPPL92018a Med.00c 04/2018 ObAua.10.2021 12:08PNICM DCI IOWA fA)U19 lo.No.9215 P. • , i STATE OF IOWA Criminal History Record Check Request Form Iowa *vidoo of Criminal Investigation Suppo Operations Bureau, la Floor 215E 711 Street Des Moines, Iowa 50319 (515) '%25-6088 (515] #ZS -6080 Fax I am recuesti6g an lows. Criminal iii Rocord Chock on DCI Account Number. 9967-F (tf rPPbC&WC) Send results Name Address Y.O.Dox426 1/2Ua Iowa City, Iowa 52244 Pboaa (319)336-9777 Fax 319.3594142 - �firr�^� B1.61 k e. �•r rr' ��ad�Tam ;i`�.'`�t`' :a: l;r C recomm' ❑Male emale =��-17ffiOR nom. . �'3 rs: �y _ ' • .,.s ��elt�'kA[js�5'v�Kl� /111Yr IDI�a 71.��, t'Wt+4�� �, ' ljp.41 el,.ihcr . Iowa Criminal History Record Check Results A,e d tr `10 '—)-) . a. scarab of the provided name and date OF IOWAII Iowa crlml l . Itysva Criminal History Record found with DCI 5 history riM litsi �(4{J( 0 9 2021 a' . ©I Iowa Giiminal History Record attached, DCI # . ' Gly C MINAL IP ,E i>xatiO DCl initials� "^ar nenmaou DCI.77 (uptQ 06-26-2018) Page I oft Received Time Aug. 9. 2021 10:42AM :No. 8910 -,. Aug• 10. 2021 12:09PM DCI IOWA No. 9215 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,11www.Iowasexoffender.com/. 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). N O N •\rte -0 �tl yf N M C A0001 J10WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN www•'owadoL gov Drhw a Identsleatlon 3stvlees PO eox 9204 I Des Moiner, IA 5000f>92W Phone 515-244-91241 Fax 515-23!9- 1&37 Certified Abstract of Driving Record Inquiry Date: 8/9/2021 DL/ID #: 563AG6309(IA) Customer #: 5900051 0S 22 2019 Name: Bllokur, Emilie Class: C ID Status: None Address: 725 S 2ND AVE Audit #: 1023533 DL Status: VAL Issue Date: 05/23/2016 CDL Status: None City/State: WASHINGTON, IA Expiration Date: 05/26/2024 CDL Cert Status: None .rE2 9 523531445 - Endorsements: NONE CDL Med Status: None ! _ C I Mailing Address: 725 S 2ND AVE Restrictions: Corrective Lenses, Restriction "Non: Left and Right Outside Mirrors, Left Supplement: - �^— `�-� W tl Outside Mirror Date of Birth: 05/26/1949 n Mailing WASHINGTON, IA Sex: F ;.-: W City/State: 523531445 History Information c -n Convictions Citation Date Conviction Data ACD I Ex lanatlon lCounty TUR 04 23 2019 0S 22 2019 S92 I Speed I IL Name: Bllokur, Emilie DL/ID: 563AG6309 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: 8/9/2021 Driver & Identification Services Iowa Department of Transporation