HomeMy WebLinkAbout15-039410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Narne (I,\[ OiJHU11.)) _
2. Address (Lll()UINIJ))
11)[IN I'll'ICATION NO. C7fli%e Use ,e Onl�y).....-
APPLICATION FOR TAXICAB / MOTORIZED PEDICAL3 VEHICLE DRIVER
(Police Department review must be rnado botwoon 8 a.m, to 3 p.m., Monday a Friday)
First
e<r Q,<nrrJ4(ry ida "s'r.Pi,r.e!" o) 'f tp`Rrq/d, vrrff I,( )Ii 6t die' iFtJt' ?:
'14';., A4 r-
Least
3. Contact Information (i d (rIfll1[-D) Email:d"g m�P1, r;ob(,) �� ��.r �, __.._.. Coll Phone , f rrr ? , „,d'L -3.-
(Allwritten comrnunic�" on sent via email)
eta. Chauffeur's license expiration date (fdiIQUII0l 7)
b. Taxicab Business Name i1t= ll[t l) _— L. Y p
_......N� ..y ......L?cr :....._t. ------
5. Prior experience in transportation of passengers:_ ,
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? _IS
Type of offense
7,ra d ix -'r �v .(. T..-.
Where
When
D Qa "+ #t" rU. ./.1m (" y., — C",d� 4dt¢ .Yr a!"na Vi' SN.a C.�yn w,`e r 6 � 9 `✓�- —
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended °. Plead Guilty Other,,,_
_ -� •t 1, ��<h,
-lave you been arrested / charged with any traffic offenses in the last five years? ")c s, —_----
Type of offense Where When
yn<r d;naj ..ld nnsam C` -P -S /a454
4"a ap�enedt.., - o.l' 1�� �i� i� o the charge? (Circle one) � ....__ hi,
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?
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)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
YOU rrulst apply for an irldividual Department of Crilninal Investigation Report (form available upon recluest).
(Sl=iCOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION Y OF TAXIC:AB VEHICLE E DP IVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
—ta .L_r .. ._ _...__ _.. _._-. issued on d�(j.f 3__ ..... _expiring on z........... I understand that if
falsely answer any questions in this application, that this a plication may be 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, aril I further agree that, if authorization to be a taxicab driver 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)
r i
Signature of Applicant....., .. �i'.:. .. _-__..- Date 'A.'�.,.F./,S
r.*
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and
to before
by J r a
this 4 h r„ , clay of
*RRkkA******k****************kkR***k**kk*xk*****R*RkR*kk9*k**RR***********R*****kRk**R*z***xR*k**FRkRk**k**kRk***k*k*******k************k***A***
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter -
ruined 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).
Signat yfe df Polio C (ef or designee Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FRONI °'I HE DATE LISTED BELOW.
THE EFFEC'T'IVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS'T°HAN A YEAR.
aturitr
Sign '
City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
c!erwrarioeivanocenPPL9201aain.�ded DOG 0212015
VVWWA0Wadbt. OV
SMARTER I SIMPLER I (USTQMER DRIVEL;
Office of Driver Services
PO Box 9204 ( Des Moines, [A 50306"-9204
Phone: 515-244-9124 1 HO -532-1121 [ Fax: 515-239-1837
vNew-fov7adot.gov
Inquiry Date:
2/25/2015
Name:
Smith, Timothy Paul
Address;
220 S CHESTNUT ST APT 2
City/State:
NORTH LIBERTY, IA 523179111
Mailing Address:
220 S CHESTNUT ST APT 2
Mailing City/State:
NORTH LIBERTY, IA 523179111
Convictions
Certified Abstract of Driving Record
OL/10 #:
S56ZZ4072 (IA)
Customer #:
2042987
Class:
D
ID Status:
None
Audit#:
6615605
DL Status:
VAL
Issue Date:
01/15/2013
CDL Status:
None
Expiration Date:
01/13/2018
CDL Cert Status:
None
Endorsements:
3
CDL Med States:
None
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
1/13/1975
Supplement:
Sex:
M
History Information
'itation Date
Conviction Date
ACD
Explanation
County
Sun
0/12/2012
11/13/2012
592
;Speed - -
Johnson
1A
7/13/2013
09/10/2013
592
Speed (10 mph &under In 3555 mph zone)
Johnson
iIA
9/20/2013
10/29/2013
M34
;Fail to Obey Traffic Sign/Signal
Johnson
,IA
9/20/2014
10/30/2014
S92
;Speed
Johnson
.IA
Name: Smith, Timothy Paul DL/ID: 556ZZ4072
Pursuant to Iowa Code 4321.10, 1, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by the Office
of Driver Services, that this Is a true and accurate copy of an official record currently in the custody of sold 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:
'• r%9r
IOWA •• y';
2/25/2015
D. 0. T.
DRIVER $`
Office of Driver Services
hpc•�������c
Iowa Department of Transportation
Name: Smith, Timothy Paul DL/ID: 556224072
State of Iowa
Division of Criminal Investigation
215 E. 7a' Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 515/725-6080
Iowa Criminal History Record Check
Walk -In Request
Yom name: -Mm-4-1m, P401 n '
Address: 220 5 Ji A 4 �Z
City/State/Zip: a,r H b zsl
Phone #: I9.,- 2s-• 8")3
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name Apellido (mandatory)
FirsttName Primer Nombre (mandatory)
MiddleName Segundo Nombre (recommended)
S re) 4- �
/ l ivt, 4t51
R.v I r
Date of Birth FechaNacimienro (mandatory)
Gender Cenero (mandatory)
Social Security Number (recommended)
1'13/-7 S-
Rmale ❑Female
/�8S•9(o>•3-23s-
Waiver Signature Fiona (If the request is on yourself, please sign. If the request is on someone else, write N/A.)
Results DCt USE ONLY
As of Z �LI I , a name and date of birth check revealed:
❑ No record found
0 Record attached DCI # CJ Lf3�j
DCI initials 1W
Receipt
Number of requests I x $15.00 per last name = Total amount $ 5• D O
Method of payment: cash money order 10 g check # MasterCard or Visa
(Last 4 digits)
Cardholder's name
DCI initials
Credit Card #
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
Exp. Date
IOWA CRIMINAL HISTORY DCI 00543519
MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1
DATE PRINTED -
2015/02/24
DCI:00543519
NAME: SMITH,TIM
SMITH,TIMOTHY PAUL
DOB SEX RAC HGT WGT EYE HAIR SKN POB
19750113 M W 602 200 BRO BRO MED IA
ADDITIONAL IDENTIFIERS
SC ABDOM
SC BREAST
CCH RECORD ***
O1 ARRESTED 19970124
AGENCY: IA0180100 CHEROKEE PD
CHARGE NO- 01 IA STATUTE IA714-2-2
THEFT 2ND DEGREE
TRK#: 015588501
COURT DISPOSITION
AGENCY: IA018015J CHEROKEE CO DIST COURT
COUNT NO- 01 IA STATUTE: IA714-2(5)
THEFT 5TH DEGREE
CHARGE CLASS: MISDEMEANOR CONVICTION
TRK#: 015588501
SENTENCE DISP EFF DAT
FINE $65 19970506
COURT COSTS 19970506
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.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION(
1