The URL can be used to link to this page

Home My WebLink About14-061 Authorization Number t — ( f • i • i (Office Use Only) _� ...; 111404.ilia me•zniffir CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX �ereKirs MicJde Last T/ 1. Name 1w /Pt ory 2. Mailing Address S 1 c Fa;r-e r'd 51 �j pt,,a (pr±y 1 3. Telephone: Home r7YO O ') 1"A- ! 5 01 Other: 4. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When 1Aa.5Se.)i 0 r1 PPS /CO O S ala II 14 arra-)n,-c4-1-- _To ? e ADD 6. Have you ben convicted of operating a motor vehicle while under th influence of alcohol or drugs in the last five years? AA) Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? ++rCtt �PS Type of offense nWhere When i'o.5on);44.1 GK'S ,10;#1<5 ,2-011 Oriviny wiH;le Suspeiu/ / y (- 1� 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? K9,..5 ape of offense Where When pr;r1 JP Svc e4I l 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) derldtaxidrivbadg 03/2013 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number '-I 3 3Z z. 9 AGO • . 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) `3 Signature of Applicant�E%- lL v./Y�'1r'7/�I Date ��_) 21) � y 09 PIS ************************************************************************************************************************************************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by r t\S rn:c s.� ' `� U or . On this �3 _ day of a.y-u. ao ttt . N. ;• ' blic in and for he State Iowa -r) \ ,..„ ************************************************************************************************************************************************ 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). L Signat o Pot e rphief or designee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. S(2 ignahotre of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5 '/z" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update clerkRaxidrivbadgeapp2010.doc 03/2013 .. SiAM 4:11rvww.Iowadot gav SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Box 9204 I Des Moines, IA 50306-9204 Phone: 515-244-9124 [800-532-1124 I Fax:515-239-1837 • wwvr.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 3/5/2014 DL/ID#: 433ZZ9200 (IA) Customer#: 4719025 Name: Thorn, Derek Michael Class: D ID Status: VAL Address: 812 FAIRCHILD ST Audit#: 7788490 DL Status: VAL Issue Date: 02/13/2014 CDL Status: None City/State: IOWA CITY, IA 522452832 Expiration Date: 02/15/2018 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: 812 FAIRCHILD ST Restrictions: SR Required Restriction None Date of Birth: 2/15/1979 Supplement: Mailing City/State: IOWA CITY, IA 522452832 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 05/24/2009 06/30/2009 ,864 'No Insurance Card Benton IA 05/24/2009 06/30/2009 S92 Speed Benton IA 10/01/2011 11/10/2011 _A33 Drug/Drug Related Conviction Polk IA 01/07/2012 ,03/21/2012 1320 Driving While Suspended, Denied, Cancelled, Revoked Johnson IA Accidents -Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number _ JUR -- 01/30/2011 .x. -01/30/2011 624719 IA Sanctions ' I Type Effective End ACD Explanation Occurrence JUR JUR Suspended_ :07/01/2011 11/28/2011 ;D38 Fail to Post Security for an Accident ,IA IA Revoked ;12/29/2011 06/25/2012 A33 Drug/Drug Related Conviction . IA Cancelled 05/02/2012 06/25/2012 W00 Not Entitled to Issuance 'IA IA Revoked 06/26/2012 j12/22/2012 825 Driving While Suspended, Denied, Cancelled, Revoked IA IA Name:Thorn, Derek Michael DL/ID: 433ZZ9200 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: tMar, 7. 2014 4: 05PM (Div of Criminal Investigation NNo, 1348 PP. 2/6 • . it311, STATEW IOWA ,,<<t9rre, ;Wsfrrt r ` to CrimminallIIllgtoryRecoidCllneek t T, 1;� l ed A Request Fort. . ,: • • DCIAccountNumber: 4' X2li - I_ (Irepplloeble) To: Iowabivislon of Criminn(rnyestigaSon From: City of towa city Support Operations lureau,l"F(oor City Clerk's Office 215 k1,7h Street 410 Z.Washington Street Dias Moines,Iowa 90319 (515)725.6066 • Iowa Lilly, IA 62240 (515)735-6090 Fax Phone: 319-3964041 • Fax: 319-356-3497 •I am requesting an Iowa C5•lminal Aisto Record Check on: Last Name(mendelory) First Name(mandatory) Middle Name(rrroienleaded) • Tib r rl 'ereKAi Date of Birth(mandatory) Gender Onendetoty) Social l/Security�Number Oteoniimended) 002/l q/' t7 Iy NCdMaio ®b'emale 2 ! 1 J / $,-. l Gme/ Waiver Information:Without a signed waiver from tlldsubJectolthe mutat)acomplctocriminal history record may not be releasable,per Code of Iowa,Chapter 692,2.For comnle(q arimtnal history record information,as allowed by law,always obtain a waiver signature from the subject of the request, )a(ver'iteiease:Iheiehyglye permission for the above requesting oflfchl to conduct an Iowa criminal history record caeckwith the Division of Csinarnel Investigation(DOI My criminal history dataconum mo that ismainlwined'bythohoDCI may boreleaseddaaassallowed bylaw. WaiverSigna(ure: 4 • " i . "(/-1_ U1/4astd. P� Iowa Criminal History1Record CheckResulfg .(DtJLsaori t .�.-: :'- -7,-, is As of 3 \") • t 1 , a search of the provided name and date of both revealed: - C) N .; • c-f,:, b w t Cl No Iowa Criminal History Record found with DCI a=1_. 5 , p -)41 5 -Flt' IV Iowa Criminal History Record attached,DCI# —)01 r Ttr t I(i„l Received Time Mar, 5. 2014 1 :47P1 No, 4408 Mar. 7. 2014 4: 05PM Div of Criminal Investigation No, 1348 P. 3/6 IOWA CRIMINAL HISTORY , DCI 06709275 MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF 2 DATE PRINTED- 2014/03/07 DCI:0070927S NAME: THORN,DEREK MICHAEL DOB SEX RAC HGT WGT EYE HAIR SKN POB 19790215 Dr 47 509 240 BRO BLK FAR OH ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y CCH RECORD *** 01 ARRESTED 20031011 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA708-11 STALKING TRK#: 100978901 COURT DISPOSITION AGENCY: /A052015.7 JOHNSON CO DIST COURT COUNT NO- 01 TA STATUTE SA708.7(4) HARASSMENT / 3RD DEGREE - 1989 COURT CASE ID; 06521 AGCR066721 CHARGE CLASS: MISDEMEANOR CONVICTION TRIO: 100978901 SENTENCE DISP EFF DAT JAIL 7D 20031103 FINE $50 20031103 02 ARRESTED 20050025 AGENCY; IA0520200 IOWA CITY PD CHARGE NO- 02 IA STATUTE XA124.401(1D) POSSESS CONTROLLED SBUSTANCE SCHEDULE I/WITH INTENT/DELIVER TRK#: 101631902 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 02 IA STATUTE IA124.401(1) (D)-F CONTROLLED SUBSTANCE VIOL. COURT CASE ID: 06521 FECR073521 CHARGE CLASS: NON CONVICTION TRH#: 107.631902 SENTENCE DISP EFP DAT DEFERRED JUDGEMENT 20060428 PROBATION 5Y 20060428 DISCHARGED FROM 20081204 DEFERRED JUDGEMENT 03 ARRESTED 20111001 AGENCY: IA0770300 DES MOINES PD CHARGE NO- 01 IA STATUTE IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE TRK#: 7BOOPHE01 COURT DISPOSITION AGENCY: IA077015J POLK CO DIST COURT COUNT NO- Mar. 7. 2014 4: 05PM Div of Criminal Investigation No. 1348 P. 4/6 DCI 00709275 PAGE 2 OF 2 01 IA STATUTE IA124.401(5) POSSESSION OF A CONTROLLED SUBSTANCE COURT CASE ID: 05771 SRCR250387 CHARGE CLASS: MISDEMEANOR CONVICTION TM: 7BOOPHE01 LICENSE REVOKED SUBSTANCE ABUSE EVALUATION SENTENCE DISP EFF DAT SUSPENDED JAIL 180D 20111110 JAIL 180D 20111110 FINE $315 20111110 PROBATION 1Y 20111110 COMMUNITY SERVICE 25H 20111110 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OP CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PB IC RECORD BUT CAN ONLY BE RELEASED TO NON-LAW ENFORCEMENT AGENCIES THE DCI. IN THE ABSENCE OF FIN ERPRINTS 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