HomeMy WebLinkAbout23-007 0 07/17/2023 3:53 PM CT GREMLER WEALTH -413193565497 pg 3 of 7
p IDENTIFICATION NO. 23. 00 7L
j _ 1 (Office Use Only)
Application Fee: $15.00
_ APPLICATION FOR NON MOTORIZED PEDICAB DRIVERtHORSEDRAWN DRIVER
CITY OF (OWA CITY (Police Department review must be made
IWO 1Es1 Wauhi❑51 Da Srr"i between 8 a.m.to 3 p.m., Monday—Friday.)
Iowa Cite, !owe )2249.1526
(314) 35615090
(514) 356-5997 FAX
First Middle Last(
1. Name (Re:quirec) - '�, Ci1/_L {
2. Address
3. Contact Information(Required) Email rive.-% 1Aiy tAi Phone: °3I 5-- 3„2't '— r `NC`lCI
4a..Driver's License expiration date(IRecluiiud)_
b. Pedicab/Horsedrawn Business Name(RCCluired}_ 1 GX 1
5. Prior experience in transportation of passengers: t
G. Have you ever been arrested/charged with any misdemeanors anchor felonies in this State or elsewhere?
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? _ Lin
Type of offense Where When o
ti
� 1
What happened to the charge?(Circle one) = tv
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 Whian ---
r�;
9. Have you ever applied to be an Iowa City pedlcab/horsedrawn driver using a different name? If yes, please provide the
name(s)
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)
vie kMon Mubraed PadmaWHorse prawn Dnve App doe 0312015
0 07/17/2023 3:58 PM CT GREMLER WEALTH 313193565497 pg 4 of 7
I hereoy ertify that I have issued to me by the Iowa Deper pent of Transportation a va id Driver's license number
q rj 1cQ/�. -If7n issued on� 0 -Z. expiring on O bbl understand that if I
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falsely answer any questions in this application, that this applica on may be denied. I agiee th t 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, Ch pier 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date / 7- 20
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STATE OF IOWA }
COUNTY OF JOHNSON }
Subson ed and sworn to before me
by On, his r7r'"Fs day of
Notary Pu (RcTT4ind for the State o owa
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I have reviewed this application, DCI report, and the State certifier) 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 licenseSYj
Iia
nature of Police hief or designee I 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. ru
THE EFFECTIVE DATE WILL MATCH THE DRIVER'S LICENSE EXPIRATION IF LESS THAN A YEAR.
Sig azure of City Cl6rk or designee I Datef
A...W W.1i.Mk...A<+MMI...+IH1.I.IfY1M..M..YM..+if'.M...f+f1t.NN1*JV M...N..fIM\.+.II...1.Y1.*11..N.e.Yk/1111iY.e.,.:lF„i1Y.Y.eIMwHaw
Office Use Only
Approved application
DCI report
State certified driving record +s GARY Q. HARMS
Website update °$commission Number 840705
My Commission Expires
• ow July 12, 2025
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O 07/17/2023 3:56 PM CT GREMLER WEALTH ->13193565497 pg 7 of 7
Slate of loava
Division id,crianliwnall hive"Aiga&Im➢
215 PL 711Strect
Des li'dohlcs,lows 50319
Phone: 515.725,6066 fleas: 515.725,6080 % �44"
Iowa Criminal History c�g�tt�e
Record Check
"alk-in Request
Your name::
Address: _
fat lffiate/za : �'� �a..' C�"G1 " Pill in all shaded areas.
}?latane Number:
Requesting au Iowa record check ow
Last wane.9}ocd(idu(mandgtxrrY) First NPAme Nelrtlar;`VarzvGre onamizoory) Middle Name Svv-nda Noma,,{mconm ended)
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Date of Birth 7 •.d:rzNaomiew (5nyvml.rcorv} Gender c......( andnu,,y) Qociall�ecuri$ N➢➢rCLitie➢'Uttoonumund tl7
Male
Female
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Release ArathoriZration., Wthoia it signed rcloin.c Frani the suh}ecr of the recluesl,a compldc criminal history record Islay not be mfE nisable,per Codc of
Iowa,Chapter 692.2. Rn cimpkQe criminal history record in Fomratictn,as,allowerd by raw,aboiin a sgncd release From ihr stibINct oC;he rcquest.
[hereby authorise an Iowa criminal history record check on myseif with the,Division ufCrimeual tnvcstigndon(13Q. Aiiv criminal history dara.concemiing
me that is rnnlvlained by¢inn€ (A stay bc relcased zs allowed Ery iaw. I understand this cem nts:htde.infi:rrardJoo curcctning coe.ipteted QcGa irxRjudgeu�cirls
and an'cats without[IisposiYiirus. a°this foftn k�Cl-&3b iti the on}y approved vcficaec:au[➢I,ttriztiticszt form Pur chis pug7oseJr
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Release Autharization Si nature
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Results nci Ustsa�d
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As of l , a name and date of birth check reuexl'ed" s rn
o record found �� {
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✓' Crn4)
Record attached,DCI #
rr v
rn va
DCI initials _.
Receipt
Number of requests x $15.00 per last name= Total arnount$_IL _ ' —'
Method of payment: 2..' cash money order check# iv_FagerCE& or til4sa
• •f-.,(Lml 4 digits)'
Cardholder's namc
DCI initials -._.
ti
DCI-83 (01/09/19)
Q01UWA00T . -
MOTOR VEH[CLE D1VIVON
110 Lux rUI,4 Dcs Moi;ics,IA 50306 92G-
'-,15244..9124(p'i) 515-'_3, 163Y lfiix� v:vrvs.i-nvdjotgovv
Certified Abstract of Driving Record
Inquiry Date: 7/19/2023 DL/ID#: 976AA8700 (IA) Customer#: 1952764
Name: Lippold, David Class: A ID Status: None
Andrew
Address: 2545 SE 1st St Audit#: 6372574 DL Status: VAL
Issue Date: 05/27/2022 CDL Status: VAL
City/State: West Des Moines, IA Expiration Date: 05/08/2030 CDL Cert Status: Non-Excepted
502658304 Interstate
Endorsements: Motorcycle CDL Med Status: Certified
Mailing Address: 2545 SE 1st St Restrictions: Corrective Lenses Restriction None
Supplement:
Date of Birth: 05/08/1966
Mailing West Des Moines, IA Sex: M
City/State: 502658304
CDL Medical Examiner's Certificate
Certificate Specifics Explanations
Medical Examiner First Name David
Medical Examiner Middle Name
Timothv
Medical Examiner Last Name Ber
Medical Examiner License Number 2023
Medical Examiner National Registry Number 9848042399
Medical Examiner Jurisdiction IA
Medical Examiner Phone
515 964-6974 —
Medical Examiner Type *--��`
Osteopathic Doctor
Medical Certificate Certificate Restriction 1 Wearing corrective lenses - ti
Medical Certificate Issued Date 08/12/2021
Medical Certificate Expiration Date 08/12/2023
Date Added to CDLIS Driving Record 05/27/2022
History Information
Convictions
Citation Date Conviction Date .ACD _IExplanation County _7UR
01/07J2021 101/24/2021 F04 Seat Belt Violation .Dallas IA
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date Case Number _ _ IA
�
02/1412014 1785970 IA
Name: Lippold, David Andrew DLJID: 976AA8700
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:
4 Ajnr uc r„ 7/19/2023
Qs
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Motor Vehicle Division
4 DDYIuIowa Department of Transporation
Name: Uppold, David Andrew DL/ID: 976AA8700
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David _
First Name E
.VUT
Andrew
f City of
Middle Name � �
LIPPOLD
Last Name
D-Taxi
Business Name
�. 23-007 -
Iowa City Permit ID
08/02/2024
Permit Expiration Date
David a
First Name
3 �
Andrew
f City of
Middle Name �lj�y
LIPPOLD �rA
Last Name
D-Taxi
Business Name
�. 23-007
Iowa City Permit ID
08/02/2024
Permit Expiration Date