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Home My WebLink About23-004 J,. IDENTIFICATION NO. Z 3'00 4-1 A _ 1 (Office Use Only) --.1M. Application Fee: $15.00 77►► ®n11 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 410 East Washington Street Failure to complete the "required"information will result in denial of the application Iowa City, Iowa 5 2240-1 826 (319) 356-5040 Last First Middle (319) 356-5497 FAX 1. Name(REQUIRED) S(3 u Y /#I / / i f 2. Address(REQUIRED) 7.c, r)O 10 t L Vl ro t..rIJ G64,-tc/ 'r/� C 2 L Li 0 3. Contact Information (REQUIRED) Email: Cell Phone: 3 ) CI"�?j'1- S 7 (All written communication sent via email) 4a. Driver's License expiration date(REQUIRED) 0 a/a3/2 a 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 elsewher6Z Type of offense Where When N tS-- l c vi& &rfam-* U 6hnrrtn 4 i c -b - z 2\ 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? /l/0 Type of offense Where When r. What 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? n v 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) n0 (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 1, 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 certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number of 1 . C f } - e 9 issued on r/t)ei_4 paring on . /Z.3) -7 . I understand that if I falsely answer any questions in this application, that this application maybe denied. I agree 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 provisi ns of Tit e 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date -7 2 O_2 3 ************************************************************************************************************************************************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by A ; 1" r-.) i rl a_ on this = Q day of riVNUM S.MAYER commission Number72M2. Notary Public in a for the State of to I „' 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). a Expiration date of Driver's license 2-1 L5/ Zd7.—7 - �4 , t 7(.1 ZrrL Sign ure of Police chief or designee D 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 ia_H- 1 - _-_-22 Sign a ure of City Clerk o designee Date Office Use Only Approved application V DCI report / State certified driving record V� Website update �/ Clerk/TAXIDRIVBADGEAPPL92018amended.DOC 04/2018 .a DDT Certified Abstract of Driving Record Inquiry Date: 7/20/2023 DL/ID#: 212CC1704(IA) CDL Permit Class: None Customer#: 224197 Class: C CDL Permit Issue None Date: Name: Sourya,Air Audit#: 4067757 CDL Permit Expiration None Date: Address: 76 EROBI LN Issue Date: 08/08/2019 CDL Permit None Endorsements: Expiration Date: 02/23/2027 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522403067 Endorsements: NONE ID Status: None Mailing 76 EROBI LN Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 522403067 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 2/23/1958 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation JUR County 09/09/2012 11/20/2012 A20 Operating While Intoxicated IA Muscatine Operating While Intoxicated Test Refusal/Test Failure Violations Occurrence ACD Explanation JUR County 09/09/2012 A98 OWI Test Failure IA Muscatine Sanctions Type Effective End ACD Explanation JUR Occurrence JUR Revoked 09/20/2012 09/19/2013 A98 OWI Test Failure IA IA Name: Sourya,Air DL/ID: 212CC1704(IA) Pursuant to Iowa Code §321.10, I, Melissa Gillett, 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 offjie; and that I have been authorized by the Director of the Iowa Department of Transportation to so certify. C 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 f1,? P4MENY❑c IqSti' , '+l'r, 7/20/2023 °P .' 0 0 ` ' � C"� °F, Kati Motor Vehicle Division c/A(Docu� Iowa Department of Transportation • Name: Sourya,Air DL/ID: 212CC1704(IA) • r0.Jul, 10. 2�J23tU 1 : 36PM FAX DCI IOWA, No. 6522 P. 4/902,002 STATE OF IOWA ).�' , •A ,r lip, 1 /� °* } Criminal History Record Check "' Yam. ;.' Request Form rv, 1, +a Its;OA DCX Account Number: q D(Z - F (if applicable) Mail or Fax completed forms to Send results to: Iowa Division of Criminal Investigation Name city of Iowa City ----- Support Operations Bureau, 1"FIoor City Clerk' s Of flee 215 E,711'Street Address 410 E,., Washington St, 1-. _•, ___ Des Moines,Iowa 50319 (515)725-6066 ;Cows City, -�A5,2240 _. „ (515)725-6080 Fax Phone 319-356-5041 . Fax 319-3S6- 49L__ I am requesting an Iowa Criminal History_Record Check on: ; ____ T —_- Last Name (mandatory)) _.__First Name(mandatnt�) _ Middle Name (recommended) — Date of Birth(mandatory) Gender(mandatory) Social Security Number(recommended) _ 2 - 2. 3. ç 2 Male OFemale Release Authorization: Without a signed release from the subject of the request,v 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, always obtain a signed release from the subject of the request. _ — ''This form (DCX-77) is the only approved release authorization form for this purpose.*** Release Authorization.. l hCroby glue permission 1'or the abot'o t'equotuiag official to conduct au Iowa criminal history record Check with the Division or Criminal investigation MCI). Any criminal history daw concerning rue that is maintained by the OCI may be released ne allowed by law f understand this can include information concerning completed deferred judgments and arrests wit tool dispositions. Release Authorization Signature:_M _ _.�,..______ _._..-.-- -------------,_-- Iowa Criminal History Record Check Results cmCl use only) ``0\`\`ttnttllnitlibl iip,ip////J C �� Cc i UTLi ilq� ' G-i As of 7/D , a search of the provided name and date of b li�lvO tiled;,., ,..41G ;. y .z.- ,..a .• •-e '---' rn No Iowa Criminal HistoryRecord found with DCI _ 4 rimina� �' �, et : Iowa C nci o :history result*; o o` pf Iowa Criminal History Record attached, DC:I fJ 70?119 m c1 cn DCl initials _e ��''ii.,,,-re,,,. . at Li DC1-77 (updated 06-26-201 e) Page I oft Jul. 10. 2023 1 : 36PM DCI IOWA No. 6522 P. 5/9 IOWA CRIMINAL HISTORY DCI 00726093 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 2 DATE PRINTED- 2023/07/10 DCI:00726093 NAME: SOURYA,AIR TOLAM,AIR VANVANG,AIR DOB SEX RAC HGT WGT EYE HAIR SKN POB 19580223 M A 505 150 BLK BLK LBR 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 (B) OPER VEH WH INT (OWI) / 2ND OFF TRK#: 068581601 COURT DISPOSITION AGENCY: IA006015J BENTON CO DIST COURT COUNT NO- 01 IA STATUTE: 1A321J.2 (A) OPER VEH WH INT (OWI) / 1ST OFF COURT CASE ID: 06061 OWCR009227 CHARGE CLASS: MISDEMEANOR CONVICTION TRT(#: 068581601 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT TIME SERVED 12H 20040909 SUSPENDED JAIL 25D 20040909 JAIL 30D 20040909 FINE $1000 20040909 PRORATION lY 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 OWCR049026 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: MA0074W01 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT TIME SERVED 71) 20121120 ' Jul. 10, 2023 1 : 36PM DCI IOWA No. 6522 P. 6/9 DCI 00726093 PAGE 2 OF 2 SUSPENDED JAIL 180D 20121120 JAIL 187D 20121120 FINE $1875 20121120 PROBATION 24M 20121120 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 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) . IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD TS BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY_ DIVISION OF CRIMINAL INVESTIGATION • l J Airl = Atliap First Name so., City of Middle Name c` SOU RYA //77 Last Name Big Ten Taxicab Business Name 23-004 Iowa City Permit ID 07/24/2024 Permit Expiration Date • t, Air First Name "III 00, City of A Middle Name 4, Verr SOU RYA Last Name Big Ten Taxicab Business Name 23-004 it Iowa City Permit ID 07/24/2024 Permit Expiration Date