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Home My WebLink About22-002 IDENTIFICATION NO. 22 — OCR Z i r 1 (Office Use Only) Ata ..40,;,igt,„ ... ......zaT ��_ APPLICATION FOR TAXICAB/MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m.to 3 p.m., Monday-Friday) CITY OF IOWA CITY 4 I 0 East Washington Street Failure to complete the "required"information will result in denial of the application Iowa City. Iowa 52240-1826 (319) 356-5040 Last First Middle (319) 356-5497 FAX N � �12-o1. Name(REQUIRED) v iQ+ �; V 2. Address(REQUIRED) .1 to 6 'APJ 3. Contact Information(REQUIRED) Email: (WSW(v01 \Q @a S"Cel1 Phone: 'a- d 3`1 -q L (All written coHmunication s t via email) 4a. Driver's License expiration date(REQUIRED) 0 2 122 I 1'1,1 b.Taxicab Business Name(REQUIRED) ig,`1 C..wfkikkj 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? Type of offense Where When M Y- 1•AvfCLI4 CNYVAA.1 2p kZ What happened to the ch . (Circle e) Convicted ismissed 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) V - 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? N t 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) IcNils (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 orkfy thatI ave issued to me by the Iowa e a nt of Transportat' n a alid Driver's license number issued on expiring on' . I understand that if I falsely answer any questions in this application, 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant d', 57(pc Date 3 i\ "ZZ STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me b ( on this 2 _r day of i\U.k ASHLEY A JAY-PLATZ /] a , Commission No.785030 (f My Commission Expires Notary Public i .r he State : o iu^* July 14,2UL 3 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 1? Signaturvif P lice 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. Signs re of City Clerk or d signee *********************************************************** ************************************************************************************ Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAXIDRIVBADGEAPPL92018amended.DOC 04/2018 Mar, 18. 2022 9: 31AM DCI IOWA No. 5629 P. 1 r•./ tit ,,;Y., ,Y. STATE OF IOWA r 1`+;,I IA'Iritv.A!,i) '' ' tr ``. CriminalHistory Record Check ,`bra` ;,•, ,,,• `ir, ,^ p ' �`�•:.';::� . rev 4 ),/.1)� y Request Form yY 0 DCI Account Number: (if appiieabla) To: Iowa Division of Criminal Investigation From: City of Iowa City Support Operations Bureau,1.E1 Floor City Clerk's Office 215 It.711i Street 910 E.Washington Street Des Moines,Iowa 50319. (515)725-6066 • Iowa City, IA 52240 (515)725-6080 Fax Phone: 319-356-5091 • Fax: 319-356-5497 I am requesting an Iowa Criminal History Record Check on: Last Name (mandatory) Mint stt Name(mandatory) Middle Naliine(recommended) Soutgfri /4i � Date of Birth(mandatory) _ - Gender(n hdaiory) Social Seet city Nuiirtliber(recommended) kf$aZ fV Waiver Information:Without a signed waiver from the subject of the request,a complete crimi i9lliistor-y5recora'In ay not be releasable,per Code of Iowa,Chapter 692.2.For complete criminal history record inform atiou,.asalloweirby law,..always obtain a waiver signature from the subject of the request, . —~', N.) `w r ut Waiver Release:l hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation(DCI), Any criminal history date concerning me that Is maintained by the DCI may be released as allowed by law. ._....&- . • Waiver Signature: • �\N1t1N1 !Il //rh,4 Iowa Cri nlma . ils,tory Record. ec _'.......,.te r. '% o . ro - c(ncr use only) As of % Ze22 , a search of the provided name anc€date o�� sled: : `�O ? = d . Y �� : (� � rn r ID No Iowa Criminal History Record found with DCI %�r /ts,•� , �' bZ , V r,l �Q .......• ,,` F I+'-. k1 0 110IOJI SeCtia'lii ��\ON Y 2 i Iowa Criminal History Record attached, DCI# O04'?1v09� DCI initials kg- DCl-77(08/25/10) Mar, 18. 2022 9: 31 AM DCI IOWA No. 5629 P. 2 IOWA CRIMINAL HISTORY pCZ 00726093 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 2 DATE PRINTED- 2022/03/18 DCI:00726093 NAME: SOURYA,AIR TOT,AM,AIR VANVANG,AIR DOB SEX RAC HGT WGT EYE HAIR SKN POE A 505 7.50 ELK ELK LER YY ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y TAT CHEST TAT L ARM TAT UL ARM CCH RECORD *** 01 ARRESTED/TAKEN INTO CUSTODY 20040606 AGENCY: IA0060000 BENTON CO SO CHARGE NO- 01 IA STATUTE IA321J-2 OWI 2ND OFF TRK#: 068581601 COURT DISPOSITION AGENCY: IA006015J BENTON CO DIST COURT COUNT NO— 01 IA STATUTE: IA321J.2 (A) 4.= OPER VEH WH INT (OWI) / 1ST OFF CD COURT CASE ID: 06061 OWCR009227 — j CHARGE CLASS: MISDEMEANOR CONVICTION r-- TRK#: 068581601 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION t:s? SENTENCE DISP EFF DAT TIME SERVED 12H 20040909 c.;n SUSPENDED JAIL 25D 20040909 JAIL 30D 20040909 FINE $1000 20040909 PROBATION 1Y 20040909 02 ARRESTED/TAKEN INTO CUSTODY 20121001 AGENCY: IA0700000 MUSCATINE CO SO CHARGE NO— 01 IA STATUTE IA321J.2 (B) OPER VEH WH INT (OWI) / 2ND OFF TRK#: MA0074W01 COURT DISPOSITION AGENCY: IA070015J MUSCATINE CO DIST COURT COUNT NO— 01 IA STATUTE: IA321J_2(B) • OPER VEH WH INT (OWI) / 2ND OFF COURT CASE ID: 07701 OWCR048026 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: MA0074W01 • DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT TIME SERVED 7D 20121120 Mar. 18. 2022 9: 31AM DCI IOWA No. 5629 P. 3 DCI 00726093 PAGE 2 OF 2 SUSPENDED JAIL 180D 20121120 JAIL 187D 20121120 TIME $1875 20121120 PROBATION 24M 20121120 03 ARRESTED/TAKEN INTO CUSTODY 20211001 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA708.2A(2) (A) DOMESTIC ABUSE ASSAULT TRZ(#: 1b0031101 An arrest without disposition is not an indication of guilt. This record maintained by the Iowa Division Of Criminal Investigation, Bureau Of Identification is a public record but can only be released to non-law enforcement agencies by the DCI. 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.."- N =� 232.147 (18) . co _ r Additionally, criminal history data concerning convictions for certain juvenile sex offenses can be found on the Iowa Sex Offender Registry: http://www_iowasexoffender.com/ _ However, even though some information is rrt 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) . IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION io/e, Z1 1 l I SMARTER I SIMPLER I CUSTOMER DR VE __�-� Dorver&idegvIdit.ation SeIVIces PO ecx&IN I[#es fittings. Cyl3M204 Phone:e:515244-91 1 Fax:51.5-2,39.10.57 Certified Abstract of Driving Record Inquiry Date: 3/22/2022 DL/ID#: 212CC1704 (IA) Customer#: 224197 Name: Sourya,Air Class: C ID Status: None Address: 76 EROBI LN Audit#: 4067757 DL Status: VAL Issue Date: 08/08/2019 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 02/23/2027 CDL Cert Status: None 522403067 Endorsements: NONE CDL Med Status: None Mailing Address: 76 EROBI LN Restrictions: NONE Restriction None Supplement: Date of Birth: 02/23/1958 Mailing IOWA CITY,IA Sex: M „.a ;,.,„ City/State: 522403067 History Information ',NI') Convictions LI Citation Date Conviction Date ACD Explanation County JUR 09/09/2012 11/20/2012 A20 Operating While Muscatine IA Intoxicated Operating While Intoxicated Test Refusal/Test Failure Violations Occurance ACD Explanation JUR County 09/09/2012 A98 OWI Test Failure IA Muscatine Sanctions , Type Effective End ACD Explanation Occurrence JUR JUR Revoked 09/20/2012 09/19/2013 A98 OWI Test Failure IA IA Name: Sourya,Air DL/ID: 212CC1704 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