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Home My WebLink About15-097r At�i�� CITY OF 1 ITY 410 fast Washington Strcet Iowa City, Iowa 52240-1826 (319) 3S6-SO40 (319) 3S6-5497 FAX IDENTIFICATION NO. / b-- (—)q,-7 (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAS VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) Fwd......,. _ _ _ _ 1. Name (REQUIRED) I It tj 2. Address (REQUIRED) 2-$ 3. Contact Information (REQUIRED) Email. at � u (All written coc 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) A yr er, 5. Prior experience in transportation of passengers: Middle Last n >1 Cell Phone: 3 i 'y' 3 q i1 t S'. 2 sent via email) V 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or Tyelsewhere? r� Type of Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? /-+ Type of offense Where What happened to the charge? (Circle one) When 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 _ wl,oh cn 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please a th4amerr++�..�� DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIr") W DRIVING RECORD MUST ACCOMPANY THIS APPLICATION F You must apply for an individual Department of Criminal Investigation RepUM POLICE CHIEF REVIEW ort (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have -ex irin on o I understand that if I issued (issued to me by a Depart entof Trransgportation a valid Chauffeur's license number on ay be denied . ree in ng this application, I falsely nsw r any qu istiO sithiss olf the City oftIowa CityaIowa, n their discretion, to exami e any and toall comply and consent to allow ageremploye documents relating to this application, and I further agree that, if authorization o e i taxicab driver o granted, to comply at a 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) ��c Date Z� Signature of Applicant _.a,...... �— STATE OF IOWA ) COUNTY OF JOHNSON ) 9�. this �-k day of 1 h h Q�� b ibed and sworn to before me by on , Su scr n 0 SIS'. I certified iving of and I have there is no wedinforthis a application, DCI indicate that the tate, a wouldrbe detnmedntal tolthepsalfetythealth or welfare ofreshat dents of the C' of Iowa City (Title 5, Chapter 2, City Code). r., ii fA rlatia f Chauff is license I ba e - Signature r rol IIcSr�� OAUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO AFTER APPROVAL BY THE CITY CLERK MORE THAN ONE YEAR FROM THE DATE LISTED BELOW Signature Of City Clerk or designee Approved application DCI report State certified driving record Website update ClerkrrAXIDRNBADGEAPPL92olAamended DDC Date 0312015 N ca Office Use Only i< s La C ` N 0312015 JWADoT +Otf+ce of Qfl sr set,cces Sh1 tT 4 il'. I § i C'JS1Q NAE pO Eotl `9204' Des fAourzs. IF, 991s37 PhanE: 635-2+W-9124 1: WS s32 11211 Eww' 1owadot.gov Name: Adams, Adil Daoud DL/ID: 713"6075 certify that I am Director Of Office of Driver Services, Iowa Department of Transportation, do hereby Pursuant to lova code §321,10, I, Kim Snook, that this is a true and accurate copy of an official record currently in the custody o1 the Office Lh�D�erct Services, oftheIowa Department of Transportation to so certify the custodian of the records held by at Ankeny, Iowa this date: said office, and that I have been authoriz by artment to he set upon this document, in witness whereof, I have caused my signature and the seal of the Dep V�Ti10D B/`r4ii 4/29/2015 IOWA Office of Driver Services It 8110�O�-- Iowa Department of Transportation Name: Adams, Adil Daoud DQID: 713yY6075 Driving Record Certified Abstract of Customer #: 431.346 DL/ID #: 713YY6075 GA) ID Status: None Inquiry Date: 4/29/2015 Adil Dacutl class: A DL Status: 8518548 VAL VAL Name: Adams, 2532 BARTELT RD APT SC Audit #: CDL Status: 10/09!2014 Cert Status: Non -Excepted Intrastate Address: Issue Date: Date: CDL 0 1/01120 2 CDL Med Status: None City/state: IOWA CITY, IA 522462720 Expiration Endorsements: LNPT Restriction Lenses, CDL None RD APT SC Restrictions: Corrective Supplement' Intrastate Only, Mailing Address: 2532 BARTELT Class A Bus Date of Birth: 1/1/1959 IOWA CIN, IA 522462720 Sex: M Mailing City/State: History Information -- Crsun'�y 7ttw. Convictions ExpSanatirxn Johnson IA Cnnv�c2ecan Dat+< 6.cD er Signal or Failed to Signal Johnson dA Date N40 - .mprOP _ — Fail to Obey Traffic Sign/Signal 3ohnson IA - -0912912011 ::0211812011 M14 Fail to Obey Traffic Sign lohnso� IA E014 01/28/2013 M74 -- to Obey Traffic SignJSignal 03/20/2014 M34Fail ion. ion. a citation. individual was at fou or given --- involvement indicated does NOT mean the UR Accidents - Accident Case Number IA Accident Date 696745 _ IA 07/27/2012 719855 01/04/2013 Name: Adams, Adil Daoud DL/ID: 713"6075 certify that I am Director Of Office of Driver Services, Iowa Department of Transportation, do hereby Pursuant to lova code §321,10, I, Kim Snook, that this is a true and accurate copy of an official record currently in the custody o1 the Office Lh�D�erct Services, oftheIowa Department of Transportation to so certify the custodian of the records held by at Ankeny, Iowa this date: said office, and that I have been authoriz by artment to he set upon this document, in witness whereof, I have caused my signature and the seal of the Dep V�Ti10D B/`r4ii 4/29/2015 IOWA Office of Driver Services It 8110�O�-- Iowa Department of Transportation Name: Adams, Adil Daoud DQID: 713yY6075 State of Iowa Division of Criminal Investigation 215 E. 7'4 Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk-in Request Results As of 4-? 9-15 , a name and date of birth check revealed: kNo record found Record attached DCI # DCI initials ILQ. Fill in all shaded areas. DCI USG ONI Y N ?c vo N -n O ? N z r_ w Receipt Number of requests x $15.00 per last name = Total amount $� X money order check # MasterCard or Visa Method ofpaymcnt: —h —cash _ Y (Ia,t4dipts) Cardholder's name DCI initials ------ -------------------------------------------------------- Exp. Date Credit Card # DCI -83 (09/()g/ 10; Revised 10/ 1 / 10; form reviewed o8/ 11/14)