HomeMy WebLinkAbout23-003 •
IDENTIFICATION NO. 2.5~ co
_ 1 (Office Use Only)
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gym m;ter
+ imam i ar Application Fee: $15.00
APPLICATION FOR NON MOTORIZED PEDICAB DRIVER/HORSEDRAWN DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East Washington Street between 8 a.m.to 3 p.m., Monday-Friday.)
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First Middle Last
€-1. Name (Required) 1> '\ ar,..A 17 5
2. Address(Required) 'L.U01- S'4 Avg... 5 F Acrivs A 52 '°3
3. Contact Information (Required)Email: Q- p (Q,9w c.Gil Cell Phone: 3 1 1 • 350 '77 2 1
4a..Driver's License expiration date(Required): s>S C Z. Zi i s
b. Pedicab/Horsedrawn Business Name(Required): ('-c)w I /oowIr.
5. Prior experience in transportation of pas engers:
y 4.1 f(A,‘( t�r`��
6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? . -IA)
Type of offense Where When
5 -(t, y. 4((-1k Po- ' Cc,4—ir /04 >c ftoyey
What happened to the charge?(Circle one)
Convicted Dismisses Deferred Deferred Suspended Plead Guilty Other
7. Have you been convicted o any traffic offenses in the last five years?
Type of offense Where When
44 h , 5,e4 Li,tn C0,1-1 r )(/Z7/20/
What happened to the charge?(Circle one)
Convicted Dismissed Deferred Deferred Suspende Plead Guilty Other ;^,.,
8. Has your driver's license or chauffeur's license been suspended or re 'rifle last five years? ~,
Type of offense' Where Wherr) r' 3
I
9. Have you ever applied to be an Iowa City pedicab/horsedrawn driver using a different name? if 'es, ple se proo/ ,the
name(s)
Ala
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)
clerk/Non Motorized Pedicab/Horse Drawn Drive App.doc 03/2015
1 hereby certify that I have issued to me by the Iowa Depart rent of Transportation va'd Driver's license number
�, •
issued on 9 17-0 2D'LD expiring on S 124 24. I understand that if I
flfalsely answer any questions in this application, that this application may be denied. I agree tha 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 a license 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 �-°''''''---- Date 6 S� 2
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by t 5u,`tcQx4— . On this day of
-U.0 P .7-c2 Z• .
WENDY S.MAYER Notary Public i nd for the State of I a
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety,health
or welfare of residents of the City of Iowa City(Title 5, Chapter 2, City Code).
`\ _ l
Expiration date of Driver's license S/Z -i fzo2_t-
fSignare of Police Chieflor designee 4 ate
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A PEDICAB/HORSEDRAWN VEHICLE
IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH T E DRIVER'S LICENSE EXPIRATION IF LESS THAN A YEAR.
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Signat re of City Cler designee D
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Office Use Only
Approved application fir-,.' w a
DCI report f/
State certified driving record ✓ '`:-2 z. 177
Website update�' ....... t
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derk/Pedicab Non Motorized Horsedrawn Driver APP 2015.doc
Iowa Division of Criminal Investigation tr
Criminal History Record Check Request Form
DCI AocoInt member(ffeppiads)
REQUESTOR INFORMATION
Name(business orindlvtduaq Mailing address(otreet/PO Bar,city,slide,r4o code)
Benjamin D Snyder 2002 5th Ave SE Cedar Rapids,IA 52403
Phone number Fez number Email address
(319)350-7729 ben@ pedaipower.onfne
I would like the roadie sent to Inn by: 0 Mall 0 Fox O Email
I am required to haw the results notarised: OYes O No Mor cpsemo requirements In mother emery wiz
SUBJECT OF REQUEST INFORMATION.Multiple rotes require•separate Request Form and fee.
LAST NAME(required) FIRST NAME(required) MIDDLE NAME(recommended)
Snyder Benjamin D
DATE OF BIRTH(required) GENDER M,F or Other(requked) 6OCIAL SECURITY NUMBER(recommended)
5I24/1983 M 153866851
RIMS'AUTHORITATION INFORMATION:Waxed a Bland release tan ate subject dthe requed,a complete aIothd Wary record may not be
releasable,per Code of Iowa,Chapter 6922 For goreglt(t aMhtal history nerd hformdlm,as clawed by law,always obtain a signed release ton tie
subject ofthe request Thle ram(001-7n lathe mN removed Mean authorisation form to tine omen,
This response only Includes sahib criminal Nday date.Under Iowa law,modlavmb records waonlldadw.Cadidentd Juvenile card wade cannot be
Included In this mesons,.A signed release aulhaUatbn lend welded to obtain this Ina:melba from the DCL In order to requed the release of oartdanhl
Menge records,If any,an eppgoalion mud be feed pasuantto Iowa Coda 232147(16)hough tie Oak at Court Criminal history data eserening
oomleac isfor whin penile sea dfemo can be found online through the the law Sex Offender Registry(SOR).Bran though can.hbnedlat Is
evalame anther trough Fe SOR,the actual record,for Jsrvahi,s may dal be confidential and cannot be podded.In order to request tie release of
confidential jamb reoada,ff any,an epploslbrh must he Red prowl to lava Code seam 232147(16)through the perk d Coin.
(BMW AUTHORIZATIaM:1 hereby WyeDemlesbnfartla above,auesSnac kdelto conduct an terra edmhsl Wow reoord OM:kwth the
oMlbnafcds*,arinvaedna nlocn Any oat reel h'-devdarieaieenddow uotle ttV,rdsnedtvlra DClnrbe reaaaavasdkwe be L-w
'understand this can leaked,in!onrrtbnconeem/m eoroletod deem dWaimmnm sod wrests weevil!d,ocsifom,Iunderstand thesionebng
below meals end Infornatkoporevtdedl,bhpendeoermr.Purestmrom Iundengand ails to an official statement and record.AnvHat
ldMneppg)mods In fhb record mey result rnfwrhof sc tton,
RELEASE AUTHORIZATION SIGNATURE Benjamin D Snyder 40 CTifnt11ry,,,,-of'�ro
FOR ACI USE ONLY �; er
As of Le a parch of the bdomution provided revere ere
e•Iowa criminal
jp� o .history results;a s
ONO IOWA CRIIIUNAL HISTORY RECORD FOUND WITH DCI
OAN IOWA CRIMINAL HISTORY RECORD WAS FOUND.A COPY OF THE.. ,•gIIZ 1 CI11
I_ �fiiibilntt0.irhCRtol`�`
(17) Practised by G rM1
By completing these forms online,your request will be automatically sent to DCI for processing after dicking°Submit°.
PLEASE NOTE: When submitting a request online-do not submit the same request by mail,fax or e
so,it will be treated as a new request requiring payment STATE OF lo �'
FormDC1-77t27/71 MAY 2 5 2023
DIV OF CRIMINAL INVEST
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Kim Reynolds . • " Department of Public Safety
Governor
Adam Gregg Stephan K.Rayons
Lt.Governor Commissioner
Junel,2023
To Whom It May Concern:
The following individual,BENJAMIN D SNYDER,requested an Iowa criminal history record check from the
Iowa Division of Criminal Investigation.
The attached search request indicates there is not an Iowa criminal history record for
BENJAMIN D SNYDER,Date of Birth 5/24/1983,with the Iowa Division Criminal Investigation.
auza
gnature
�••'� '"A\� \opawnnuuunrry
o Criinirrlllf%
Iowa Division of Criminal Investigation ?'/• .
Bureau of Identification a ' p
Iowa criminal
.a
o,.history results
•
State of Iowa ../
° sefninnti 0'S�o�`°
County of Polk oNgunnununwao
This instrument was acknowledged before me on 6/01/2023
Date
B Carrie Kautz VALERIE KAY i31159
Y •Name(s)of Person(s) • My c rir21Oa s•
\J
Signature of Notary Public
Clerk Specialist
Title
DIVISION OF CRIMINAL INVESTIGATION•215 EAST 7TM STREET•DES MOINES.IOWA 50319-0041•515-725-601Q
Integrity,Fairness,Respect,Honesty,Courage,Compassion,Service
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GIOWA DOT - �
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•
•'f MOTOR VEHICLEf3IVISION
``FO8NYer
ox9204 Des Molnes,IA,56306-9204
515-244-9124..(ph) :g15-239.1837(fezl www{towad0Lgov
Certified Abstract of Driving Record
Inquiry Date: 6/1/2023 DL/ID>?: 854ZZ7418(IA) Customer#: 4245770
Name: Snyder,Benjamin Class: C ID Status: None
David
Address: 2002 5th Ave SE Audit S: 4999154 DI.Status: VAL
p Issue Dote: 09/28/2020 CDL Status: None
City/State. 5 40327pi s,IA Expiration Date: 05/24/2024 CDL Cart Status: None
Endorsements: Motorcycle CDL Med Status: None
Nailing Address: 2002 5th Ave SE Restrictions: NONE Restriction None
Supplement:
0 p Date of Birth: 05/24/1983
City/State: 524032713 s,IA Sex: M
History Information
Convictions
Citation Date Conviction Date ACD Explanation ,County 3UR
11/27/2019 12/22/2019 M14 Fall to Obey Traffic Linn IA
Sign/Signal
Accidents-Accident Involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date Case Number 3UR
07/29/2018 1061019 IA
09/25/2019 1135459 IA
10/24/2021 1267149 IA
(1) Name:Snyder,Benjamin David DL/ID:854Z27418
Pursuant to Iowa Code§321.10,I,Melissa Gillett,Director of Motor Vehicle Division,Iowa Department of Transportation,do
hereby certify that I am the custodian of the records held by Motor Vehicle Division,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
;
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177
,: ':-
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this date:
p,VgN �7 OF 7q4 6/1/2023
( ))
ct
% ,yr Motor Vehicle Division
't/AL Do, Iowa Department of Transporatlon
Name:Snyder,Benjamin David DL/ID:854227418
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Benjamin
iu
First Name corir
David Q Cfty of
Middle Name
SNYDER
Last Name
Pedal Power
Business Name
23-003. 113
Iowa City Permit ID
z
05/24/2024
Permit Expiration Date
''‘Celgt
110
Benjamin
► ` 111
First Name ll. 1
David
0.0 City of
�
Middle Name j C‘
SNYDER
Last Name
Pedal Power
Business Name
,RF 23-003
Iowa City Permit ID
05/24/2024
Permit Expiration Date
ClArto