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Home My WebLink About12-010r � r !1 dmp� ®til CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX Name Authorization Number 42 12557 (Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday.) .Middle S 2. Mailing Address _�� % (� r' , / t3 ( C 0 rG,V U� 3. Telephone: Home 3\01- C 3(7- IS Other: 4. Prior experience in transportation of passengers: `)y1DD�S �� L> �� r, I /\ Ski UC'_ GI J 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Q Type of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? tA,I Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When 5; -7 ( a Sdz 7` 5 4-03' G-Z-rJQ 8. Has yo r driver's license or chauffeur's license been suspended or revoked in the last five years? VLD Tvoe 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 must apply for an individual Department of Criminal Investigation Report (form available upon request) The re- port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli- cation. (OVER FOR REQUIRED SIGNATURE AND NOTARY) Ge�axitlnvbatlg 09/2010 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number �1� Lb MIS . I understand that if I falsely answer any questions in this application, that this application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will 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 a license 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 n Signature of Applicant I Date k+klkfkkMkff NYMNN##HYN+#+##N#N+N+4####NN#Nf#NN#iN##HN#NIHHYNkiHlHlH1MY+lHIH!!f#M#H##ii#4Y#k#+###iN##+i#N##FkN#Y STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by L�4SJ; , a-/15 . On this /J day of FORT bar 159791 Emhas Notary Public in and for the State of Iowa *#R*R#R*R#*#k#k**R**t4#}ttt}t#tt1}if14t}ttRN1#f4fflRflifHfitf}tfiftNt}}ti}}*4R}#Httt}}#t#}Y*#t**kR#RR*RRR*#*RRRRRIRRRRR*RRRk1RR*fNNRRfif#f 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). Si ature ofPoliC ief or designee Signature of City Clerk or designee / -/a -ia Date After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org. Taxi cab businesses are required to provide Driver Identification cards. iflflfifHifllfff#ffYYYN#N####iHi###ff#RH##Mf;f##f###fffHMRt##fHff#####f###tM##Rf#i###N####'F#lfiffY## fi#ifi##N# Office Use Only Approved application DCI report State certified driving record Website update d.r "ddW.dgeaW2010.d 09/2010 Iowa Department of Transportation AO Office of Driver Services (Toll Free) WO -532-1121 PO Box 9204, Des Moines, 1A 5030E-9204 515-244-9124 FAX: 515-239-1837 Inquiry Date: 1/12/2012 Name: Hills, Dustin Adam Address: 418 4TH ST City/State: TIPTON, IA 52772 Mailing Address: 418 4TH ST Mailing City/State: TIPTON, IA 52772 Convictions Certified Abstract of Driving Record DL/ID #: 713XX0776 (IA) Customer #: 3984225 Class: D ID Status: None Audit #: 4808413 OL Status: VAL Issue Date: 11/09/2010 CDL Status: None Expiration Date: 05/23/2015 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Restrictions: NONE Restriction None Date of Birth: 5/23/1979 Supplement: Sex: M History Information Citation Date Conviction Date ACD Explanation County JUR 04/02/2008 _ 05/06/2008 _ _ V14 ,Fail to Obey Traffic Sign/Signal 52 ;IA 04/23/2008 06/02/2008 592 Speed ',52 IA 05/07/2009 05/27/2009 -.M14 Fail to Obey Traffic Sign/Signal ,52 IA Sanctions Type Effective End ACD Explanation Occurrence JUR JUR Suspended 09/03/2009 11/03/2009 D53 Non -Payment of Iowa Fine IA IA Name: Hills, Dustin Adam DL/ID: 713XX0776 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: >.••""••:;vi '4 1/12/2012 IOWA D. D. O.T.�s f"•'5` DBIVE4,_ Office of Driver Services Iowa Department of Transportation Name: Hills, Dustin Adam DL/ID: 713XX0776 12Dec, 20114J1_:05AM D Div of Criminal Investigation DCI Io •4168 STATE OF IOWA Criminal IUstory Record Check Request Form Toa Iowa Dhtdoo orCriraln■1lnve■traeaon Support Operaaass Lureao, L" Floor 315 E 7e Bdeet Des Melon,tornr 50319 (515) 71s6M (515) 7266(1!0 Fix • ., ., r.. a M...1«� iriw.w:.. a.:.:..,.r r h"l, nn. ot MA=un(Numbcr (Irrppriahb) Frnm•MAY-C•sTAL)(l .-.+. phone: Fur P. 4/5 wjuu4/004 9 Lad Name IHratNamo Mlddlell)ame 11,sstir, �c�am Date of Hlrth ma,e,m Gender eaeauo lal smartly Number (C=nMkQ 5- -1 Ot 1111faie Ebernee •4 -1S --v; i` �dtvdrirffOrwarriarrr without a dpud wlwer Gem the ■ab)ed of rbe roque■t, ■ eamplete CdMtad history record m■yoat be nke■able, per Cede of lora, Chapter 672.7. For=k12 ortmhut Wory reenrd tafhrmt1w, v Owed by taws ■May■ obr■lo wafvw ig stare rrumth ■ ed of the ural Walveri:Eftare:lbaeg dr°i'mWbefard�d+rertgwrlma oafaYl ro faWrulnd Aiewdbyhelacl;ulte a,o pjrivm ofGimiell torlerrprbnlbCq• nen oAnl"w101an,ydbparvnfptnteLLYnuballoa liner mis>tdr moweghw. Waiver Siggg-A-1 (oc[uealy) As of I a' F-- I ) , a search of the provided flame and date of birth revealed: ❑ No Iowa Criminal History Itocord found with DO r Iowa Criminal Hlatory Record attached, I fY DC1 inilialsAZ Received Time Dec.20. 2011 10:35AM No -6627 Dec -28. 2011 11:05AM Div of Criminal Investigation IOWA CRIMINAL HISTORY DCI 00592134 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 1 DATE PRINTED- DCI:00592134 2011/12/20 NAME: RILL9,DUSTIN ADAM DOH SEX RAC NGT WOT EYE HAIR SKN POB 19790523 M W 511 210 ORN BRO MED IA ADDITIONAL IDENTIFIERS SC LF ARM SC R PGR CCH RECORD **t 01 ARRESTED 19990211 AORNCY: IAO160300 WEST BRANCH PD CHARGE NO- 01 IA STATUTE IA713-1 BURGLARY 3RD DEGREE TRKO: 034056201 SENTENCE CHARGE NO- 02 IA STATUTE IA714-1 THEFT 3RD DEGREE TRK#: 034006202 DEFERRED JUDGEMENT COURT DISPOSITION 19990430 AGENCY: IA016015J CEDAR CO DIST COURT COUNT NO- 01 IA STATUTE IA713-6A BURGLARY 3RD DEGREE TRK#: 034056201 RESTITUTION SENTENCE DISP EFF DAT PLEAD GUILTY 19990430 DEFERRED JUDGEMENT 19990430 COURT COSTS 19990430 PROBATION 2Y 19990430 COURT DISPOSITION AGENCY: IA016015J CEDAR CO DIST COURT COUNT NO- 02 IA STATUTE IA714-2(3) THEFT 3RD DEGREE CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 034086202 SENTENCE DISP EFF DAT PLEAD GUILTY 19990430 FINE Wo, 19990430 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD TAIMBD HY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF NTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW CEMENT AGENCIES BY THE DCS. 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 No. 4168 P. 5/5