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Home My WebLink About23-006 r IDENTIFICATION NO. 2-5-00 p 1 _ 1 (Office Use Only) ---.= r( 111111. 4►► +� AOImi�� Application Fee: $15.00 may`— APPLICATION FOR NON MOTORIZED PEDICAB DRIVER/HORSEDRAWN DRIVER CITY OF IOWA CITY (Police Department review must be made 4 10 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) D' ' I J r� C� r I tS'" 2. Address(Required) S (/0 l'7Y 1 ,67 f' %f1q, e" .4 — 6 3. Contact Information (Required)Email: to 1 Lrc— 4i DHftpre 41 5/5 1Z" V/ of 4a..Driver's License expiration date (Required): / if /7 1 7 ZIZB b. Pedicab/Horsedrawn Business Name(Required): J i fr 5. Prior experience in transportation of passengers: ,3 f,'ye-`,, 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? /1,/ 0 Type of offense Where When What happened to the charge?(Circle one) ,�, Convicted Dismissed Deferred Deferred Suspended Plead Guilty Other 7. Have you been convicted of any traffic offenses in the last five years? Type of offense 410 Where When What happened to the charge?(Circle one) Convicted Dismissed Deferred Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Type of offense Where When 4id 9. Have you ever applied to be an low ty pedicab/horsedrawn driver using a different name? If yes, please provide the name(s) 1 V 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 Dave App.doe 03/2015 I h ? ertify th, t I issued to me by the Iowa D rtm t o Transportation v d river's license number • issued on Z expiring on I understand that if I falselylan� ryn�uestidns in this application, that this a I' atio maybe denied. I agr a in makingthis application, I y PP PP 9 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 applica ' n, 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 e City Code.e'(Needs to be signed in front of a Not Pu ic) Signature of Applicant /C_--&---- Date L3 RESA M PRESTON *'*` Commisson Number 832395 �; Lily Commission Expires aw June 04,2024 STATE OF IOWA - COUNTY OF- ) Su scr ed ark r to before me by , . On this f tir day of Notary Pu e State of Iowa 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). Expiration date of Driver's license ~] Z� I) '1"k Signature of Police hief or designee Date 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 THE DRIVER'S LICENSE EXPIRATION IF LESS THAN A YEAR. Signat re of City Clerk or esignee JJJ Date ********************************************************************************************************************************************* Office Use Only Approved application DCI report State certified driving record Website update Gerk/Pedicab Non Motorized Horsedrawn Driver APP 2015 doc ♦1 State of Iowa • ,,. 11 Division of Criminal Investigation Air 215 E.7,h Street '� IOWA rid Des Moines,Iowa 50319 VAL ♦ Phone: 515.725.6066 Fax: 515.725.6080 ' Iowa Criminal History Record Check Walk-In Request Your name: /64 t/'►_ j ,�/ ,te- - CO r✓)e/) 0 • Address: ( 5•/ �,1r1r•.v\J b r• r..—W City/State/Zip: flt;? j i y _ Sd Fill in all shadedareas. " Phone Number: 5/5 i/q, 4l 742 Requesting an Iowa record check on: Last Name Apellido(mandatory) First Name Primer Nombre(mandatory) Middle Name Segundo Nombre(recommended) 1,0 Coo if ile 44,ei DR:),jF--_,z-.n=_. Date of Birth Fecha Nacimiento(mandatory) Gender Genero(mandatory) Social Security Number(recommended) /7/ 7 [Male n Female 3 l ' U gs- Release A thorization Without a signed release from the subject of the request,a complete criminal iiistory 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)i he only approved release authorization form for this purpose.* Release Authorization Signature G-- /0 Results "1 '`'i l DCI USE ONLY \\\`\\�'„ Cl'liililja('•/�'/1h%O .- cn As of , a name and date of birth check revealed: tio�0 '••ILA ''' 0 E?"_ No record found _ :,loW a �r;m;+�a o = ►-r r, resU�ts. _ z i—' O n Record attached, DCI # o history y N D r o DCI initials 0/ ., seminatio``St��`�� "'-i cn //n«,#,",,unmt„00 Receipt 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 C L�.� DCI-83 (01/09/19) tt V .. DOT MOTOR VEH ICLE DIVISION PO L'::x 9204 Lk I:, 'SG'3U6 r;1f.34 S15 244 9124ip•II 51S 23"i 1883/ I1,1 :, 4+Yt^V.'.IUt+rd,.lut Certified Abstract of Driving Record Inquiry Date: 7/11/2023 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 Nona DR No Class A Supplement: Passenger Vehicle rw- Date of Birth: 08/07/1967 Mailing DES MOINES, IA Sex: M &J'% City/State: 503151119 History Information CLEAR DRIVING RECORD • Name: Cornelison, David Eugene DL/ID: 747YY8517 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 this date: 7/11/2023 -M47:#9_,,4444,1 >114 cy. Motor Vehicle Division fO1�C DOC:'- Iowa Department of Transporation Name: Cornelison, David Eugene DL/ID: 747YY8517 David „ First Name � diaint i Eugene fO City of Middle Name CORNELISON Last Name Des Bike Pedicab Business Name 23-006 - f Iowa City Permit ID 07/25/2024 Permit Expiration Date David ' r First Name i bit -% Eugene �`�"— ,,Q City of � Middle Name A C� CORNELISON Last Name Des Bike Pedicab Business Name 23-006 Iowa City Permit ID Allk,,,0 07/25/2024 Permit Expiration Date