HomeMy WebLinkAbout16-107IDENTIFICATION NO. I LP-jn-�
_ r 1 (Office Use Only)
CITY OF IOWA CITY APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
410 East Washington Street
lova City, 101va S2240-1 826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
rst Middle Last
1. Name (REQUIRED)}
2 Address (REQUIRED) 25 -9C, t l/4 60, t 6�2s7l A S•� e r r
3. Contact Information (REQUIRED) Email: <d11<3 Q c, v Cell Phone: -91 E-J 69�
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 7-6 % 'yo y 20
b. Taxicab Business Name (REQUIRED) la i"-r_✓
5. Prior experience in transportation of passengers: 1 0 v S
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7 Have you been arrested / charged with any traffic offenses in the last five years? O
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?
Type of offense Where When V
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the rlme(s) (` r .7
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIF15
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF 'REM
You must apply for an individual Department of Criminal Investigation Report (form available upon1equest).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)'
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
7 ( 3 �� 6,;7 i� issued on expiring on \I I understand that if I
falsely answer any questions in this application, that this al5ffi&ation m y 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 �,of the City Code. (Needs to be signed in front of a Notary Public)
G
Signature of Applicant Date3_ �/ / f
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by %a 1 R - A cQ a a-&5 on this _ day of
) u� o Z.LnI L D
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).
Expiratidohaueur's license Q r�/ 0
at edesignee 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.
Signatu -of City Clerk or designee
Office Use Only
Z-1-3 3 //G
Date
Approved application s
DCI report
State certified driving record
Website update
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clerWrAXIDRN9ADGE PPL92074amended.Doc 03/2015
Fay. t. nVio inllrivi uiv C LYlminaI lnvtstIgation No. 3292 P. 1
From:Glty q1 Bowe Guy Clcrk Uflloe 319 5666487 0412$/pole 16:11 d"Oe P,002I002
STATE DY IOWA
c1/�>rzainal Hhsfolq Record tCheckc
To: Iowa Division of Criminal Iovesilgation
Suppart Operations Bureau; I" Fioa
215 E. 7"' Sfvetf
Des Moines, Iowa So319
(515)525-6066
(515) 724-6080 Fax
I am ret nesting an Iowa Criminal
Last Name nnnirdarnn,l
Ba
Af)A;Ms
'nI _4I -\q 39
Clmcic
AClAeeonntNuanber: `tC'0":k--{—
(irnpplicable) ---
Frvm: City of 1orV_a City ___
Ciiy Clerk's Office f --
410 F. Washington 5freet
Iowa City, IA 52240
Phone: 319-356-5041
Fax: 319.356-5497---
Male 1:11iclaiale I 5
P Y4-- o U D
T3vnivei dBfOvnllLldott: 1'Jithnut a signed rvaiverfrDin the subject of the regnesi, o complete criminal history record may not
be releasable, per Cade of Iowa, Chapter- 692.2. For complete crinlnal history record informafioa, as aliotved by law, always
Obtain a waiver slkaptw•e fro in the suh,iett of the request.
TyaiVer R61e(lSE; l ho«b
y rive permission for du above « questing olrcial to conduct nn laza rs;minel hislory mcord ehexl: wi[h rbc Division off.c Cominol
IMcSdgotinn(DCO. Any criminal hismp•dolt eonceminamc by the ACRney bereleased as enosved by law, -a
Iffeiver,
Ti®ts a Criminal lFI{iI{ tory Ree rd Check Results nci� er l,•1
h a search of the provided name and date of birth fei,ealed: n
i -;
No Iowa Criminal History Record found with llCT
IJ Iowa C1'iminal History Record attached, T)C:I
DO irlitials
Received TIimF�Anr.qAnl 9016 ?:57PM No. 441 ---------'-- �--- h
Iowa Dcapartment of Transportation
ofte of €ifuer StrfMZM std1 hlee &X-532-1121
PG Brut 97Xr4, Din W"eem€, [A 503k591204 515.244.5424
F -AX: 515 2391837
History Information
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
4/29/2016
DL/ID #:
713YY6075 (IA)
Customer #:
431346
Name:
Adams, Adil Daoud
Class:
A
ID Status:
None
Address:
2532 BARTELT RD
Audit #:
8516548
DL Status:
VAL
Fail to Obey Traffic
APT 1C
IA
Si n Si nal
Issue Date:
10/09/2014
CDL Status:
VAL
City/State:
IOWA CITY, IA
Expiration Date:
01/01/2020
CDL Cert Status:
Non -Excepted
Si n/Si nal
522462720
intrastate
Endorsements:
LNPT
CDL Med Status:
None
Mailing Address:
2532 BARTELT RD
Restrictions:
Corrective Lenses,
Restriction
None
APT 1C
CDL Intrastate Only,
Supplement;
No Class A
Passenger Vehicle
Date of Birth:
1/1/1959
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522462720
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
08/18/2011
09/29/2011
M14
Fail to Obey Traffic
Johnson
IA
Sign/Signal
01/04/2013
01/28/2013
M14
Fail to Obey Traffic
Johnson
IA
Si n Si nal
02/21/2014
03/20/2014
M14
Fail to Obey Traffic
Johnson
IA
Si n/Si nal
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Name: Adams, Adil Daoud DL/ID: 713YY6075
i
Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, 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 he set upon this document, at Ankeny, Iowa
this date:
4/29/2016
IOWA !` /
D. •5'/
Office of Driver Services
Iowa Department of Transporation
Name: Adams, Adil Daoud DL/ID: 713YY6075
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