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Home My WebLink About16-140nor®dl� • ,�` r"III � CITY OF IOWA CITY 410 Eas[ Washington Strecr Imu Cit y.Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO Ho -140 (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) Failure to complete the "required" information will result in denial of the application 3. Contact Information (REQUIRED) Email: SC.Orp;oPOPS(t�'cr �4J. COM Cell Phone:3 512- S737 (All wri en//co munlcation sent via email) 4a. Driver's License expiration date (REQUIRED) )/U q/Zd) b. Taxicab Business Name (REQUIRED) C 1� 5. Prior experience in transportation of passengers: YP U10CO S T)I 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where Whe r 05�OQ 7 a What happened to the charge? (Circle one) Convicted Dismissed Deferr Suspended Plead Guilty Othe[':` Have you been arrested / charged with any traffic offenses in the last five years? ''3 What happened to the charge? (Circle one) Convicted DismissedDeferred Suspended Plead Guilty Other Has your driver's license or chauffeur's license been suspended or revoked in the last five years? e 9. Have fou 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). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 0712016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify hat I have sued to me by the Iowa D �r t of Transportation a vali Diver's license number �!v YY o% d issued on 1 tD expg on l ( 61 — 1. 1 understand that if I falsely answer any questions in this application, that this applica ion 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 ApplicantDate Z5 �ro STATE OF IOWA ) COUNTY OF JOHNSON ) ibed and sworn I to before me by 1 7C� b t +�-1 iG�Ct <' ✓ l i on this � ' ' � day of u+ KELLIE K. TUTTLE Commission Number 2216 tary Public in and for the State of Iowa - 0 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 CCod"e).� ` Expiration date of Driver's license I ( / / ?,.o1 t Signature of Pi' ie or gnee _R/2Date �pGG� 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. J� ka1,le11) Sign tore of City Clerk or designee /i1/1 Date Office Use Only Approved application DCI report State certified driving record r:' Website update '7 � 3 AA ClerkrrMIDRNBADG APPL92014amended.DOC 07/2016 C410WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN 4EIWW'lOVhIcCIOt CgOV Orrice of Driver Services PO Box 9204 1 Des Moines, IA 10306-9204 Phone: 515-244-91241 800-532-1121 1 Fax: 515-239-1837 www.lowadot.gov Certified Abstract of Driving Record Inquiry Date: 7/26/2016 Dll #: 769YY4850 (IA) Customer #: 4224396 Class: D Name: Middaugh, Gabriel Abraham Audit #: 1128478 Address: 2115 3 ST APT 2 Issue Date: 07/06/2016 Expiration Date: 11/02/2018 City/State: IOWA CITY, [A 522402047 Endorsements: 3 Mailing 2115 3 ST APT 2 Restrictions: NONE Address: Restriction None Mailing IOWA CM, IA 522402047 Supplement: City/State: Date of Birth: 11/2/1984 Sex; M History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: Explanation CDL Permit None Endorsements: Revoked CDL Permit None Restrictions: IA ID Status: EXP DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None Citation Date Conviction Date ACD Explanation County ]OR 03/06/200805/21/2008 Revoked A20 Deferred Judgment OWI Johnson IA 03/06/2016 03/31/2016 592 ::Speed (10 mph & under in 35-55 mph zone) Muscatine IA Operating While Intoxicated Test Refusal/Test Failure Violations Doom'rence ACD Explanation JUR 03/06/2008 IA98 I DWI Test Failure IA Sanctions Type Effective End ACD Explanation Occurrence JUR JUR Revoked iO3/17/2008 09/12/2008 IA98 ]OWI Test Failure IA IA Suspended '0711 Fi'70'_2 ;08102/2012 '.D51 'Kion -Payment of Child Support '!A IA Name: Middaugh, Gabriel Abraham DL/ID: 769104850 Pursuant to Iowa Code §321.10, I, 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 be set upon this document, at Ankeny, Iowa this date: ''�ENICIf p� o� s� IOWA s' �`�®f OIIIVfN ��i Name: Middaugh, Gabriel Abraham DL/ID: 769VY4B50 7/26/2016 ly-�'� Office of Driver Services Iowa Department of Transportation F,Jul.28. 2016„ 4:12PM ,,,,Div of Criminal lovestigat:on Q7/28/201r; IS: No, 9263,rs&F,, 4/52,1o02 STATE OF IOWA Criminal History Record Check r Request Fora, To: Iuwa Division of Criminal raves -ligation Support Operations Bureau, ){I Flnor 215 L, 7"' Street Des Moines, Iowa 90319 (515) 725.6066 (515)925-6000 Fax Criminal DCI Account 1\"lobar:. _ >07 -J= Front: _ Cwt-, of Sows City _ CityClerla'; pkfrce-_--�--�-"---- 410 E. Wasbtn 1� un rtrcef_ IowaCIS, IA 12240 Phone, 319-1%-5041 Fax: 319 -356.5497 --- -LA 1V8111C (mandatory) First Narne (mandatory) 1i'jidalC N&lI1C (recommcndcd) —/ Allo 11/6 z/Jq s`7 Male ❑Female ocial SOCnrity Number (rccommende ff/a'pel'.ififOl-r]aM6011: M111out a signed waiver AM the subiect of the request, a corgle(e criminal hislory record may not be releasable, per Code of Iowa, Chapter 692.2. For cow crlmillal history record information, as allowed by law, always obtain a waiver si natwo krona the suLect of the reauest- WftiVer R6169SC: I herchy give pomaisaion for Ille above «gsusling official to waded an lows criminal history rwrd check ttilh the Divisimi of Criminal lnvetligation (DCI). My criminal history data ooncemiog Inc that is maims b he aCl91 y be released as allowed by la,v. Waiver Signature; Iowa Ciriyninal History Record Check Results PCI use only) a search of the provided name and date of birth revealed: m ® No Iowa Criminal History Record found with DO ry 1 Iowa Criminal history Record attached, DC1 ii qi� �,I U b _L F 1 DCI initials 4-4 I b DCI -77 (08/25/10) Received Time Jul. 26, 2016 1:25PM No, 0329 Jul.28. 2016 4:12PM Div of Criminal Investigation ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y TAT L SHLD TAT LP ARM TAT NECK TAT R SHLD TAT RF ARM CCH RECORD +'** 01 ARRESTED 20060306 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA321J.2(A) OPER VER WH INT (OWI) / IST OFP TRK#: lAO03KO01 COURT DISPOSITION AGENCY; IA052015J JOHNSON CO DIST COURT COUNT NC- 01 IA STATUTE: IA321J.2(A) OPER VEH WH INT (OWI) / IST OFF COURT CASE ID: 06521 OWCROB2561 CHARGE CLASS: NON CONVICTION TRK#: IA003KO01 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EPP DAT DEFERRED JUDGEMENT $625 CIVIL PENALTY 20060521 PROBATION lY 20000521 UNSUPERVISED TO DCS DISCHARGED FROM 20090213 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU 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 FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION I Nc.9283 P. 5/5 IOWA CRIMINAL HISTORY DCI 00626846 NON CONVICTION PACE 1 OF 1 DATE PRINTED - 2016/07/26 DCI:0062804U NAME; MIDDAVGH,GABRIBL ABRAHAM DOB SEX RAC HGT WGT EYE HAIR SKN POB 19641102 M B 500 145 BRO ELK LBR MI ADDITIONAL IDENTIFIERS PHOTO AVAILABLE: Y TAT L SHLD TAT LP ARM TAT NECK TAT R SHLD TAT RF ARM CCH RECORD +'** 01 ARRESTED 20060306 AGENCY: IA0520200 IOWA CITY PD CHARGE NO- 01 IA STATUTE IA321J.2(A) OPER VER WH INT (OWI) / IST OFP TRK#: lAO03KO01 COURT DISPOSITION AGENCY; IA052015J JOHNSON CO DIST COURT COUNT NC- 01 IA STATUTE: IA321J.2(A) OPER VEH WH INT (OWI) / IST OFF COURT CASE ID: 06521 OWCROB2561 CHARGE CLASS: NON CONVICTION TRK#: IA003KO01 DRUNK DRIVING SCHOOL SUBSTANCE ABUSE EVALUATION SENTENCE DISP EPP DAT DEFERRED JUDGEMENT $625 CIVIL PENALTY 20060521 PROBATION lY 20000521 UNSUPERVISED TO DCS DISCHARGED FROM 20090213 DEFERRED JUDGEMENT AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU 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 FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY. DIVISION OF CRIMINAL INVESTIGATION I Nc.9283 P. 5/5