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Home My WebLink About21-045� r -4 �Illr+�tp•ir 7a 'moi`' �l®ff rtlm�� rl.W_ CITY OF IOWA CITY 410 East Washington Street Inca City. Iowa 51240-1826 (3 19) 356-5040 (3 19) 356-S497 FAX IDENTIFICATION NO. L I . Q C45 (Office Use Only) APPLICATION FOR NON MOTORIZED PEDICA13 DRWER/HORSEDRAWN DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) FI t— Middle 1. Name (Required)�,y" /� '�� r 2. Address (Required) I Ct ,1r+Ik.A�1 f • Df5 d`illrP 3. Contact Information (Required) Email:3eg ' k a>W r 1 Cell Phone: 4a.. Drivers License expiration date (Required): o D71202-.6, b. Pedf icab/Horsedrawn Business Name (Required); i 5. Prior experience in transportation of passengers: w ve '-)cdd l 6. Have you ever been arrestedlcharged with any misdemeanors an l6rfel6hies In this•81 W.;%s Type of offense Where rte; h _•r Last What What happened to the charge? (Circle one) Convicted Dismissed Deferred Deferred Suspended Ple�ardyGluilty Other — 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When ' What happened to the charge? (Circle one) 7— Convicted Dismissed Deferred Deferred Suspended Plead Guilty Other 8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? /W Type of offense Where When 9. Have you ever applied to be an Iowa City pedicab/horsedrawn driver using a different name? If yes, please provide the name(s) 4 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) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) I hereby e4ily that I have Issued to me by the Iowa pa ent of Transportation a v, lid Driver's license number l IV 951_ Issued on ! expiring on 8 2 . I understand that if I falsely answer ny ciestions in 1his application, that this ap Ilcati n may be denied. I ag a at In making (his 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 Thal. If a license Is granted, to comply at all times with all of the pro- visions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signahue of Applicant 6— !y/i Date Q Z 1NH11HHIIIIMf IHN111NH1NIIJfINH1NNIHH1HNiN111IiN1lHI:HIH11111HHIfHiH1YIN1H1NI1HH 111 H 1 H f H1 H1 HtN1H1fHI1N11N STATE OF IOWA ) COUNTY OF JOHNGeN POW, $ub cribed and sworn to before me by 1ZG.Vld rAync . ayY On this ,ate day of I have reviewed this application, DCI report, and the State certified driving record of this ppglleant and have deter- mined that there is no Information which would Indicate that the Issuance would be detrimedtal to thrrsafety, health or welfare of residents of the City of Iowa City (Tide 5, Chapter 2, City Code). S' nature of Police Chief or designee Dale AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A PEDICABIHORSEDRAWN VEHICLE IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. THE EFFECTIVE DATE WILL MATCH AE DRIVER'S LICENSE EXPIRATION IF LESS THAN A YEAR. lbf202/ Sign tura of City Clerk t r asignee ate HINYINIIIIIINNNNfINHH�f NHNFHININHNI IHNHNII H,tHMHNNIHMNN11H1HHfIHNHHII{MNNHi11HNiNMHHH111111NII1 ✓i Office Use Only Approved application DCI report �— State cerdfled driving record — Website update tbNP,lub Non I.b1vm1 NwaaYax,MrlPFanisaoc ,y`M\ ar YU.l fr o` 0 'r rflrn acv State of Iowa Division of Criminal Investigation 215 E. N'Strect Des Moines, Iowa 50319 Phone: 515.725.6066 Pax: 515.725.6080 Iowa Criminal History Record Check Walk -In Request Your name_ udi •dam r P t S -Address: 5.4, � x i. k �• City/Staii:17 ; hp / ,'hone Number: A/S +10 kcyucstin_gan Iowa record check an: Fill in all shaded areas. Last Name da&t,(mmdaar)) First NamePamerNnmhvImandaloryl MiddleNamC.4'e•umfnNni (rccommeaJcd) _ars-r-Il-So0 Date of Birth hn hu&,smma, (mandasoryt Gender Gene. (mandsta ) Social Security Numbe trecommend:e % /q [ P1ale ❑Female 3 f e cg Releasa Audrori; a ion/; without a signed release from the subject of the request, a camplete criminal history record may not be releeseble, per Code of Iowa. Chapter 692.2.1 or complete criminal history record infomution, as allowed bylaw, obtain a signed release from the subject of the 64hest. 1 hcrchy awhoriic on Inwu criminal history record check an myself with the Division of Criminal Investigation (DCI). Any criminal history data concerning me That is maintained by the DCI may be released set allowed by law. I usicksscnd this can include information concerning completed dclIcuedjudgemmes anJ amc.Is wilhi tat Jispo.ilinn. "This Farm lDCI-A71 is Ilseonly approved release authnA78tinn forth far this purpose.' Release Authorization Signature Are 11I.W11 Results a oast„ As of a a , a name and date of birth check revealed: o z Q No record found .r:..r O Pyq z p ar w w U ❑ Record attached, DCI N k r 0 1 rn > DCI initials — '. Receipt Number of requests x $15.00 per last name = Total amount $ Method of payment: M cash money order check # MasterCard or Visa (Lw 4 digits) Cardholder's flame DCI initials•/, DCI -83 (01/09/19) SMARTER I SIMPLER I CUSTOMER DRIVEN wAwiowadot.gov DINar a IaaM 43bon Sahicaa PO Box M Drs ?Acmes IA X34; 61201 Phone 515,244.91241 Fax W,2341837 Certified Abstract of Driving Record Inquiry Date: 9/10/2021 DL/10 l: 747YY8517 (IA) Customer 1602393 Name: Cornelison, David Eugene Clan: 8 ID Status: None Address: 1954 COURTLAND OR Audit t: 2083826 DL Status: VAL Issue Date: 08/22/2017 COL Status: VAL City/State: g0 MOINES, IA Expiration Date: 08/07/2025 COL Cert Status: Non-ExCepted Intrastate Endorsements: Motorcycle, CDL Med Status: None Passenger Mailing Address: 1954 COURTLAND DR Restrictions: COL Intrastate Only, Restriction None ti No Class A Supplement: v Passenger Vehicle p Date of Birth: 08/07/1967 �:-C--• rn Malllnp DES MOINES, IA Sex: M City/State: $03151119 History Information —t I r- CLEAR DRIVING RECORD - — Name: Cornelison, David Eugene DL/ID: 747YY8517 OY Pursuant to Iowa Code §321.10, I, Dam Doty, Director of Driver & Identification Services, Iowa Department of Transportation, do hereby certiry 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 1 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: Cornelison, David Eugene DL/ID: 747YY8517 9/10/2021 Driver & Identification Services Iowa Department of Transporatlon d11CY?Z_.•i_ V