HomeMy WebLinkAbout15-147l 1 IDENTIFICATION NO. Z_
(Office Use Only)
®4
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday – Friday)
410 Last Washington Street
Iowa city, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
First Middle Last
1. Name (REQUIRED)
2. Address (REQUIRED) 10 2q
3. Contact Information (REQUIRED) Email: _F ,er„ nr 1`i8 IL" jw c I. cocv Cell Phone: 3l I-333 $3fi y
(All writtenomm/ unicatiio ent via email)
4a. Chauffeur's License expiration date (REQUIRED) I c' 2 /20t
b. Taxicab Business Name (REQUIRED) _ J ,ckc cos S Tc x ,
5. Prior experience in transportation of passengers: -, �, V -
f ar c e 5
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? �—
Type of offense Where When
vvnat nappenea to the charge? (Circle one)
Convicte Dismissed Deferred Suspended Plead G7.ulilty Other
Have you been arrested / charged with any traffic offenses in the last five years? d `J
Type of offense Where When
What happened to the charge? (Circle one)
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? EI
Type of offense Where When
9. Have you ever applied to bean
using a different name? If yes, please provide the name(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MI EIYTI`4i THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
hereby ce tify tha� /I have issued to me by the Iowa Depa ment of Transpo tation val9d Chauffeur's license number
`f 6 Y T y 85 0 issued on (• 20 expiring on I O Z 2. _1 b . I 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 of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by %-r .�rP QV M, J& u ,4L on this day of
S. )2we1Ml Notary Public ( and for the State
III
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license t L2. 1 201
Signatu e of Pblice h of or designee
c>Zzl�xtS
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.
Signature of City Clerk or designee
7A iF//,l
Date
Approved application
I � :016tti SZ lilt D1DZ
DCI report
State certified driving record
Website update
CIeAJrAXIDRIVBADGFAPPI-92014amended.DOC 03/2015
C410WADOT
SMARTER 151MII E I CUSTO"71'_I~ DiRN'EN Www,iowadOt gaV
Inquiry Date: 7/22/2015
Name: Middaugh, Gabriel Abraham
Address: 1024 E BURLINGTON ST
City/State: IOWA CITY, IA 522403206
Mailing Address: 1024 E BURLINGTON ST
Mailing City/State: IOWA CITY, IA 522403206
Convictions
Office of Driver Services
PO li 9204' Des Moines. TA 50306-9204
Phone: 5.15-244-91241800-532-11211 Fax: 515-239-1837
www.towadat.gov
Certified Abstract of Driving Record
DL/ID 7f:
769YY4850 (IA)
Customer Au
4224396
Class:
D
ID Status:
EXP
Audit Jf:
8187148
DL Status:
VAL
Issue Date:
06/20/2014
CDL Status;
None
Expiration Date:
11/02/2018
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Date of Birth:
11/2/1984
Supplement:
Sex;
M
History Information
Citation Date Conviction Date ACD Explanation County JUR
03/06/2008 05/21/2008 A20 Deferred Judgment OWI Johnson IA
Operating While Intoxicated Test Refusal/Test Failure Violations
Occurrence
ACD
Explanation
)UR
D3/06/2008
A98
OWI Test Failure
IA
Sanctions
Type Effective End ACD Explanation Occurrence)UR )UR
Revoked 103/17/2008 09/12/2008 A98 OWI Test Failure IA IA
Suspended 07/10/2012 08/02/2012 D51 Non -Payment of Child Support 'IA - IA
Name: Middaugh, Gabriel Abraham Dll 769YY4850
Pursuant to Iowa Code §321.10, 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 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:
�4Xi6[f
�� .lid 'i
IOWA
7/22/2015
tr.
Bill
Office of Driver Services
Iowa Department of Transportation
Name: Middaugh, Gabriel Abraham Dill 759YY4850
07,Ju1 14. 2015911:22AM
e'
Div of Criminal lovestigation DCI TOKNo' 06 17
STATE OF IOWA
```'°'
Criminal History Record Check q v
Request Form
To: laws Division of Crlminal Iavert1pnon
Support Ope eflosa Bureau, I' Floor
215 L 76 Strest
Delmohles'lowa 50319
(515) 7254066
(516)72&4W Fax
I nm mawwtinp an rnwa "Minal Hialnry R" Cheek nn�
bCl Account Numhar. 3g
pr a)
Frwtn: AY ST0,XI
006s A 54)40
Phone] x(319) 359- mq
Fat:. - 319 -3-%11
3
imet Name ar,odra
Fist Name f
Middle Name
Mdd� t,9 G�a�r
�t
�1b robes
Dole of Birth
Geader
Social Security Number ,
11/0 2/19 $ H
�41[ale OFemale
384 - 9,i._ 2 2 8-'
Walver fOrmadox., Without a sl`oed waiver from the aobjeet of the request, a complete criminal history r mrd any not
be mleatable, per Code allows, Caapter 6412. For lwmeleB all nal history record information, iu allowed by law, olrray'a
b le ■ Ayf 1wrftuQUIS 6vn the subject of the requefil,
WalVdr A91000: I haebydlw,anuiran fordo above ngsnlnl o&W to omtlua M tows aims nl hImM tears cbwt,Mh are Divi ism eMim1 W
ImmdsWvu I000. Anymmhud bbtcy dM rm,ee W me &M 6 m*Wft d by O DCI tory bs nlnoad o dlawed by Nw.
Wp1Ver,1`tgd0lllrE:
J=a,crim al Mstory Record Checlk R , ulte tDc,wewarl
As of J a search of the provided name and date of birth revealed;
No Iowa Criminal History Record found with DCI r i
cn 1 1
n,
Iowa Criminal Hiatary Record ettaohed, I7CI N 00
DCT initials
Received Tiae Ju1,10. 2015 9:23AM No. 2738
Ju1.14. 2015 11:22AM Div of Criminal Investigatlun
IOWA CRIMINAL HISTORY DCI 00828848
NON CONVICTION PAGE 1 OF 1
DATE PRINTED -
D01:00828848 2015/07/13
NAME: MIDDAUGH,GABRIBL ABRAHAM
DOB SEX RAC HGT WGT EYE HAIR SKN POB
19841102 M B 508 145 BRO BLK LBR MI
ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y
TAT L SHLD
TAT LF ARM
TAT NECK
TAT R SHLD
TAT RF ARM
CCH RECORD *t*
O1 ARREBTED 20080306
AGENCY: IA0520200 IOWA CITY PD
CHARGE NO- OI IA STATUTE IA321J,2(A)
OPER VBH WH INT (OWI) / 1ST OFF
TRK#: 1A003K001
COURT DISPOSITION
AGENCY: IA052015J JOHNSON CO DIST COURT
COUNT NO- 01 IA STATUTE: IA321J.2(A)
OPER VEH WH INR (OWI) / IST OFF
COURT CASE ID: 06521 OWCR082561
CHARGE CLA55: NDN CONVICTION
TRK#: 1AO03XOol
DRUNK DRIVING SCHOOL
SUBSTANCE ABUSE EVALUATION
SENTENCE D18P EFF DAT
DEFERRED JUDGEMENT $625 CIVIL PENALTY 20080521
PROBATION lY 2000052.1
UNSUPERVISED TO DCS
DISCRAROED FROM 20090213
DEFERRED JUDGEMENT
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BURRAU 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 PUPKESHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION
No. 0817 F. 2/2