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Home My WebLink About22-010 IDENTIFICATION NO. 22 - 010 • i r 1 (Office Use Only) • -- :::1111441;ANIII ak Amageglir 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 1 Middle (319) 356-5497 FAX 1. Name(REQUIRED) C4i'itc"I l l ) �,?rf►Cf/�c'�'� 2. Address (REQUIRED) (q59 ( _1t .0 r. t) (i41 e. r ,�,. -� 3. Contact Information(REQUIRED)Email: C 'i /k i/' 434 Cell Phone: .c/5 `l/ 52z.. (All written comrrft'tnication sent via email) 4a. Driver's License expiration date(REQUIRED) D S//7 z17 b. Taxicab Business Name(REQUIRED) Pe5 I I 5. Prior experience in transportation of passengers: .__._. li �c'rst - ' z f)9/c_'J // W 1 L)\ 22c 1 ii s I/ r,`r--s q C ``d t-t aN /`$'5"a/4; 7717.`e--o/ ni , 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? 4 C) 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? 4/0 Type of offense Where When What happened to the charge?(Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other A 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 40 Type of offense Where When 9. Have you ever applied to be an Iowa City taxi drive u,ing 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 ,,c i h t I hay issued to me by the Iowa D pa ment of Transportati n valid Driver's license number I/ a 4 / .� issued on / expiring on 2 . I understand that if I falsely answe y questions in this application, that this ap lic ion may be denied. I ag ee 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 granted, to comply at all times with all of the provisio s of Title 5, Chapter 2,of the City Code. (Needs to be sign din ont of a Notary Public) Signature of Applicant Date -7 7/ 7 STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by Za.4);1 e4T'.. Lo to el a 5.c� on this Al day of 1 3.0 V—"2—. cJ ts) 0. .404cLA colaNDY S WVCo Notary Publicp andfor the State Iowa Number 729426 **************************** ******************************************************,t******£******************** 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 vlielfare of resi- dents of the City of Iowa City(Title 5, Chapter 2, City Code). Expiration date of Driver's license _ I 1 12c,(1, Sigy-7,2 Zec,, 2 a n ure of P e or designee Da e 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. 7/ Signat re of City Clerk r d signee Date ************************************************************************************************************************************************ Office Use Only Approved application ✓/ DCI report State certified driving record Website update Clerk/rAXIDRIVBADGEAPPL92018amended.DOC 04/2018 • _ of Air 1 State of Iowa Division of Criminal Investigation �'�� "`', 215 E.7"'Street r r„ V IOWA Des Moines,Iowa 50319 f AT Phone: 515.725.6066 Fax: 515.725.6080 r ,'ilil\kk.\ Iowa Criminal History Record Check Walk-In Request Your name: i vie) t CIr,i e/i jp71 Address: .5" r e,elJ r, City/State/Zip: J) Alf fet`S, z•1, .� 31.5 Fill in all shaded ireas. Phone Number: 5/ 5 1/y'/ 2/7'Z .--4 Requesting an Iowa record check on: IN.) Last Name Apellido(mandatory) First Name Primer Nombre(mandatory) Middle N jme Segundo Nombre(recommended) ed rn ell5o4 be., ii i'e) t 1...--,-4,, --;:, _ Date of Birth Fecha Nacimiento(mandatory) Gender Genero(mandatory) Social Security Number(recommended) 6 61 / 96 7 XMale I ] Female V43 c g753‘7 Release Authorization: Without a signed release from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 692.2.For complete criminal history record information,as allowed by law,obtain a signed release from the subject of the request. I hereby authorize an Iowa criminal history record check on myself with the Division of Criminal Investigation(DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law. I understand this can include information concerning completed deferred judgements and arrests without dispositions. *This form(DCI-83)is the only approved release authorization form for this purpose.* Release Authorization Signature 01,4%e C .,,,;,,0111,,,u,,,,,,,, �,,0\;"V��a D tV S ion O"'', , DCI USE ONLY '�: Results 2 1o'V` fy, As of , a name and date of birth ilNcl ira Zzewd: • � '•. C Ze N LU 0 t�No record found = t° • z r n Record attached, DCI # 4er••' ��,r .••�. . W =• 0 DCI initials C-1-- t,,,, �Ction.n�n��r ll��``� CO O n 0 Receipt G� Number of requests I x $15.00 per last name= Total amount $ 6 Method of payment: X cash money order check# MasterCard or Visa (Last 4 digits) Cardholder's name DCI initials DCI-83 (01/09/19) 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://www.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). • r) • . . olowAD0T wvim SMARTER I SIMPLER I CUSTOMER DRIVEN toWtlot.lov Driver 4 Ider►ulicstivn Set vices PO Box 9204 I Des Mines, IA _ RtxIne 515-244-9124 I Fax r I- ;' ' Certified Abstract of Driving Record Inquiry Date: 7/13/2022 DL/ID#: 747YY8517 (IA) Customer#: 1602393 Name: Cornelison, David Class: B ID Status: None Eugene Address: 1954 COURTLAND Audit#: 2083826 DL Status: VAL DR Issue Date: 08/22/2017 CDL Status: VAL City/State: DES MOINES, IA Expiration Date: 08/07/2025 CDL Cert Status: Non-Excepted 503151119 Intrastate Endorsements: Motorcycle, CDL Med Status: None Passenger Mailing Address: 1954 COURTLAND Restrictions: CDL Intrastate Only, Restriction None DR No Class A Supplement: Passenger Vehicle Date of Birth: 08/07/1967 Mailing DES MOINES, IA Sex: M ^' City/State: 503151119 History Information —4C- -I CLEAR DRIVING RECORD r.) Name:Cornelison, David Eugene DL/ID:747YY8517 £J 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: 7/13/2022 ATI. . - Driver&Identification Services /fuC Dt L—" Iowa Department of Transporation Name:Cornelison, David Eugene DL/ID: 747YY8517