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IDENTIFICATION NO ._"PP S
( ! (ORSce Use Only)
1111111111111i Application Fie:$15.00
APPLICATION FOR NON MOTORIZED PEDICAB ORIVERAIORSEDRAWN DRIVER
C+tom.
iTY OF iOWA CITY (Pollee OepaIVM•Mt review moat b.made
810 f Alt'N7+M^slo,lhcrt between Sa.m.to3p.m..Monday—Friday.)
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2 Address Slid; 5 kf (q �y ,Vei r P ��!�J
fi 3 ContactkNtxrraeorl:ri i..rr,t Entad:f�f1[j'leer '� jlR+ ir' /�.i!
4a Driver's License eapeauon date•RI,
b Pedicab.HomerInA rr+Business Name•Fe 1;r+1 J _
5 Prior expenence in transportation of passengers
i3y .� s
6 Mave you ever been arras ed,cbarged e+th any misdemeanors andlor!domes+n this Stave or etseamere' _ 1
'ripe /f rce BtStg When
what happened to the dsepe(Cade one)
Convicted Drsmssed Deemed Deferred Suspended Plead Gutty Other
Have you been convected of any traffic offenses a,the last five years'' _.
Tipp.;if Where
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What happened to the charge'(Cede one)
Convicted Dismissed C.e eneu Deferred Suspended Plead Guilty Other....
8 Has your driver kense sir chauffeur s license been suspended or revoked in Me last free years' — _.._
T116t4!_010"*. Wt1E2 Y ItiAn_
9 Heal a you ever appi.ect to be an tawjfty pedicabrl+orsedrawn dnver use+g a drf!arent:same" N yes.picka,so pro 11v
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DEPARTMENT OF CRIMINAL.INVESTIGATION(OCI)REPORT AND STATE CERTlFIE,Q_
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW I f
You must apply for an individual DepadmeM of Criminal Investigation Repoli(forth available uprrnYs qus.t6. rfn
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) ( :•y
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1 r .y Ih i 1 esued to me by tt a Io�.:r 't Ttan54r:rtatoo v 'vet s .•cen+s! ntrter
1g 5 _, rxe4ed cn ._. en .t 0,,
1 understand that d i
*iP y a,p�st�i ens n this acc-i anon,'eat My may be eer`.ed 1 m rtrduw emu aeChcaten i
ony nr In ri..*a=3entx or.yrptnyees of Iv,Cry of iota Cie, s rwa in trees Ms xrror, to examine any ano e`:rodrocordb a,rC
documents reatx+g(4)01,apRh^.. .and n hrrh,•+ I t ,r,:i! .r n .x[f S:fIM P!! In ;n"K,t'r At all trees me,ar_of The
prcvs,Wna of TNe 5,Chapter 2.c Cdy,Coe (Needs to be signed in front of a No Pu iC)
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Sgnnttae of Applicant_ — C 4 . Ja e
STATE OF IOWA
COUNTY OF a • (/�'
7
to before me by , ' ,r *CZ'. � On ea ` day of
VAZIr.Pt. - i°- ' -State 060,4
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
)(Tid/e/5.Chapter 2.City Code).
Expiration date of Driver's license 4&1]/ L
Jure
x ?4/2Chief Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A PEOICABIHORSEDRAWN VEHICLE
IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH THE DRIVER'S LK:ENSE EXPIRATION IF LESS THAN A YEAR.
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itli2e1Cityt _ to I _
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J office Use Only --,I C`
Approved epphcahon V I
DCI report ✓i j
Stale mu.,diving record 1 ,- *::aWebsde update ✓ CD;fit;'
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State of Iowa `:v«:rt t i,.`/4.,
I 'A 1`'k, Division of Criminal Investigation
215 E.7b Street
16WA ' Dec Moines,Iowa 50319r.
; .,i Phone: 515.725,6066 Fax: 515.725.6080
Aerie/
Iowa Criminal history �'�,, '4--
Record Check
Walk-In Request
Your name: J. Vt/It"I, 1 .
Address: [l,l 7.
Cl State/Zip: , s: : f ?1,—,r A T 15 Fill in all shaded areas.
Phone Number: 5-r 5 'g s s=' .'.
. Rtqueeting an Iowa record check on;
' 14st flame +r/lad,Inundatory) First Name Prewer axarr6rr(n�eedatoty) Middle Name S,ando 6wubre(-ccrrianetu1ed1
1
Date of birth Fades Mrrineaiwr Mutaditterr Gender n,a Social Securi}�Numbed tots.rnmi.nf:et
I (Lear
e 9 L' : //7f
I ,Male ❑Female 3 11 7
Release Aht o ;anon: Without a signal release from the subject of the request,a complete criminal history record may not he releasable,per Code of
lower,Chapwr 692.2.For complete criminal history record information.as allowed by law,obtain a signed rcicaic iroul the subject of the request.
1 hereby authwru art Iowa criminal history record check on myself with the Division of Criminal Inv Motion(DCI). Any criminal history data Lencernirtg
nic that is maintained by the DC1 may be released a,allowed by law. I understand this can include information concerning completed defa ed judgements
sod erreiti without diyw citions. 'This form IDCI-R}3 is the only approved releea�ass,"authorization form for this purpose'
Release Authorization Signature /)i. .i //(-
Results nr,t:sra m
FQz
As uC � ')9 _ a name and date of birth check revealed: 0 1
4No record found �' 0
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❑Record attached,DCI# _ i i• 2
D
DCI initials i,I,)' rn
rn
Receipt
Number of requests I x$15.00 per last name=Total amount$ 19.-00 _ °
Method of payment: cash money order check# '16,v2S' Ma kti:ard or Vi
.....F(Last4:14u.)
Cardholder's name 9Gty I d E i LrY1elLS(,f] _ _.
DCI initials Cr') 't
t�1
DCI-83 (01/09/19)
IOWADOT
MOTOR VEHICLE DIVISION
PO Box 9204 Des Moi,7es,IA 50306.9204
515-244-9124(ph) 515-219-183/&Ix www.iowadolgov
Certified Abstract of Driving Record
Inquiry Date: 1/24/2024 DL/ID #: 747YY8517 (IA) Customer#: 1602393
Name: Cornelison, David Class: B ID Status: None
Eugene
Address: 5400 SW 19th St Audit#: 2083826 DL Status: VAL
Issue Date: 08/22/2017 CDL Status: VAL
City/State: Des Moines, IA Expiration Date: 08/07/2025 CDL Cert Status: Non-Excepted
503154846 Intrastate
Endorsements: Motorcycle, CDL Med Status: None
Passenger
Mailing Address: 5400 SW 19th St Restrictions: CDL Intrastate Only, Restriction None
No Class A Supplement:
Passenger Vehicle
Date of Birth: 08/07/1967
CD
Mailing Des Moines, IA Sex: 2t: f
City/Ste: 503154846 );,,µ
History Information "`
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CLEAR DRIVING RECORD ---
Name:Cornelison, David Eugene DL/ID:747YY8517 C..)
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:
�g +tir+T ''I 1/24/2024
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Motor Vehicle Division
'C�4L or30 4 Iowa Department of Transporation
Name:Cornelison, David Eugene DL/ID:747YY8517
David tr
First Name qr.
Eugene � City of 3
Middle Name �44 C'
CORNELISON
Last Name
Des Bike Pedicab
Business Name
{ . , 24-005
Iowa City Permit ID
IOW
444110 08/07/2025
Permit Expiration Date --<
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oTh
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rn
1,0
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David1 gais
First Name
Eugene OCFtyof
Middle Name /
CORNELISON
Last Name
Des Bike Pedicab
Business Name
24-005
Iowa City Permit ID
4111, 08/07/2025
Permit Expiration Date
A