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Home My WebLink About15-062CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. /S-06 2— (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) Failure to complete the "required" information will result in denial of the application First / /�Iddle, Last 1. Name (REQUIRED) , jh 2. Address (REQUIRED) 571d 3. Contact Information (REQUIRED) Email: 4—i h, Cell Phone:�g6 8a (All written communication sent via email) 67M^,-1 . C- 01y1 4a. Chauffeur's License expiration date (REQUIRED) o a ` -?d Q d / � -- b. Taxicab Business Name (REQUIRED) � c,/ P e,7,6 5. Prior experience in transportation of passengers: old C CP, �7 6 6. Have you ever been arrested ! charged with any misdemeanors and/or felonies in this State or elsewhere? F, S r4f-,- / / r c, -10'fk7 e f "/ � L.' When What happened to the charge? (Circle one) Convicted Dismissed Deferred SuspendedPlead G Other 7. Have you been arrested / charged with any traffic offenses in the last five years? /L,/ Tvpe of offense What happened to the charge? (Circle one) Where When d /-), 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? �✓ d Tvpe of offense Where When ^ ry 9. Have you ever applied to be an Iowa City taxi driver using a different name? It yes, please provldra the narne(s). DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVfEUv You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I herebyc rtify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 4C a Y X X <--q Y 7 issued on 3 - /0 - -',0'4irino on /,) ' 3 c )dAj_understand that if I falsely answer any questions in this application, that this application 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, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions o Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date—a STATE OF IOWA ) COUNTY OF JOHNSON ) 1 Subscribed and sworn to before me by �1yt,1ot'L, x�'D, r_tL1_rr± A,on this / Lc7 �7 [A day of S.MAYER " u,mrr,--,,,,, 1, Notary Public in for the State I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that th m o information which would indicate that the issuance would be detrimental to the safety, health or welfare . residen#s"e City of Iowa City (Title 5, Chapter 2, City Code). or designee ylglr� Date 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. THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR. re1 J ign re of City Clerk or designeeMate n :p Office Use Only 4 _7 a Approved application _ DCI report State certified driving record '- Website update cia WAXDrwoADcraPru2014.m &d DOC 0212015 C�JIUW DOT 5NAARTE [ SHAPLEF 1 CUSTOMPR DRIVE v ICstu dt)t, ii Office of Dfiver.Services :PQ Box 9204 1 Des Moines, i.A 50306-9204 Phone: 515244-9124 8110-532::-1121 [.Fac 511-239-1837 www.iawadot.gov Certified Abstract of Driving Record Inquiry Date: 3/10/2015 DL/ID #: 428XX5987(IA) Customer #: 751729 Name: Huberty, Timothy David Class: C ID Status: EXP Address: 510 1/2 7TH AVE Audit #: 8907498 DL Status: VAL Issue Date: 03/10/2015 CDL Status: None City/State: CORALVILLE, IA Expiration 12/30/2015 CDL Cert None 522411947 Date: Status: Endorsements: NONE CDL Med None Status: Mailing Address: 510 1/2 7TH AVE Restrictions: NONE Restriction None Date of Birth: 12/30/1963 Supplement: Mailing City/State: CORALVILLL, IA Sex: M 522411947 History Information Convictions Citation Hate Conviction Date _acD Explanation County Jut? 01/31/2007 °06/01/2007 'A20 Operating While Intoxicated lohnson IA Operating While intoxicated Test Refusal/Test Failure Violations C+courren-;w t.... Expl: nz ¢ion Sista 01/31/2007 =.Al2 :OWI Test Refusal ':]A Sanctions Typ- Ef ctiv: End nc[D Expiar,ation Gaccu+rnnce JUR JUS: Revoked X02/11/2007 ;102/10/2009 A 12 '.OWI Test Refusal !IA IIA Name: Huberty, Timothy David DL/ID: 428XX5987 Pursuant to Iowa Code §321.10, I, 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 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: wp >"oENIClf a 10. Nar 11 2015 11 53AM Civ of Criminal Invesligailon "alar 10 ay.I ��,"'.„ ..,.y " Iowa -"y pdye 2 �0' 2735 P. 3/6 STATE I (DIF I q\ A"fir knAiF`u,�. *lolvt'ff �i rim inn History Recored Check ck � }� Request Yom To; Iowa Division ofCriminsllnvestlgallou Support Operatlous Bureau, I" Moor 215 E. 71, Street IDCslvlofnes,lovwa 50319 (515) 725.6066 (515) 725-6090 Fax Record Last NA mn DCI AccountNtmmber: Lb:x -G (rfapplicable) From; C6tyofIDWilCity city Clerk's Omce - 410 E. Washln&ta Street Iowa City, IA 52240 Phone; 319-356-So4i Fax. 319-356.5497 0Z Pr¢ 1 0 t/. dl Date of Birth (mendetcd) Gendyyet, (mmdcc 1 ;7C7dsmale ❑Fermlale Wafper 1P1,f&jPWa lDa: Without a signed waiver tram the sublectofthe request, a complete criminal history retard may not be releasable, per Code of lows, Chapter 692,2, For comoleta ctiminalhisiory record information, as allowed by law, always obtain a waiverslvnatnre &nm A. v,rnsa,r „rcxe —o—, - Willver Releaset1 hereby Ove permission for the ebavcyaqumting offlcial to npnduct m Iowa crinlnd bitlory ramrd died, w Lh rhe Divlaiatoxrimioal L1Vm09N1Jon (DCO. Any utminal 1110ory data maintalUA by rhe DCl may be ralrarod W allowrd by 16w. WaiverStgnalare: Iowa Criminal Mstory Record Check Results (nclbseont,l As of 3�/!//a search of the provided name and date of birth revealed: ® No Iowa Criminal History Record found with DCI Iowa Criminal History Record attached, DCT # DCI initials DCI -77 (08/25110) Received Time Mar, 10. 2015 1:49PM k2634 Mar.11. 2015 11:53AM Div of Crininal Investigation No.2735 P, 5/6 DCI 00365529 PAGE 2 OF 3 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321J.2(A) OPER VER WH INT (OWI) / SER MISD / 10T OFF - COURT CASE TD: 06521 OWCRO55841 CHARGE CLASS: NON CONVICTION TRK#: 040292501 SENTENCE DISP EFF DAT DEFERRED JUDGEMENT 20001013 PROBATION 355D 20001013 DISCHARGED FROM 20010713 DEFERRED JUDGEMENT 04 ARRESTED 20070131 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 02 IA STATUTE IA321J.2(B) OPER VEX WR INT (OWI) / 2ND OP? TRK#: 1ADOOR702 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA321J.2(B) OPER V£H WH INT (OWI) / 2ND OFF COURT CASE ID: 06521 ONCRO79556 CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: IA000R702 DRUNA DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT JAIL 7D 20070601 FINE $1875 20070601 05 ARRESTED 20070613 AGENCY: IA0520100 CORALVILLE PD CHARGE NO- 01 IA STATUTE IA708.7(2) HARASSMENT / IST DEG. - 1989 TRK#: 1A001NR01 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA708.7(2) HARASSMENT / IST DEO. - 1989 COURT CASE ID: 06521 AGCR079510 CHARGE CLASS; MISDEMEANOR CONVICTION TRK#: 1Ao01NB01 SENTENCE DISP EFF DAT JAIL 30D 20080219 FINE $625 20050219 Ma r, 11. 2015 11:53AM Div of Criminal Investigation DCI 00365529 PAGE 3 OF 3 No. 2135 P. 6/6 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 IN