HomeMy WebLinkAbout16-175CITY OF IOWA CITY
410 East Washington St reel
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO
f _5
(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
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2. Address (REQUIRED) 2 5 Z ba Pt r C :g)" i 41 Z4 , 01[h
3. Contact Information (REQUIRED) Email: rkoLdac)kd Y Zddma,Z "3Cell Phone: 31q S9u �QQj
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) -
b. Taxicab Business Name (REQUIRED) A IN rico hI oy
5. Prior experience in transportation of passengers:
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6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this StatemreLSevftre? —4v o
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?
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 '1OA Where When
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) /Vu
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)
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APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certQfy ythat I have issued to me by the Iowa Depa ment of Transportatii n a valid Driver's license number
:7 6 l--/ y-7l� issued on 6 t 1 expiring on 3/ZI72020 . 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 t r F. Citv Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant _ Date 31w-12 6
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STATE OF IOWA )
COUNTY OF JOHNSON
S bscribed and sworn to before me by q CLAg 1)Q hurl on this day of
V&WVE Notary Public in an or the State of I wa `
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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).
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designee
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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
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
GerkfT XIDRNBADGE PL92014am mw DOC 07/2016
0(;OiUWADOT
SMARTER I SIMPLER I CUSTOMER DRIVERyyWW'IOWadOt.gOV -
Office of Driver Services \'
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
1 www.iowadot.gov
Certified Abstract of Driving Record
Inquiry Date:
8/20/2016
,
DL/ID #:
769YY7191 (IA)
CDL Permit Class:
None
Customer #:
5026188
Iowa Department of Transportation
Class:
D
CDL Permit Issue Date:
None
Name:
Daoud, Abdelgados Pull
Audit #:
1244781
CDL Permit Expiration
None
Date:
Address:
2532 SARTELT
RD APT 1C
Issue Data:
08/20/2016
CDL Permit
None
Endorsements:
Expiration Date:
03/21/2020
CDL Permit Restrictions:
None
City/State:
IOWA CITY, fA
522462720
Endorsements:
3L
ID Status:
None
Mailing Address:
2532 BARTELT
RO APT 1C
Restrictions:
NONE
DL Status:
VAL
Restriction
None
CDL Status:
None
Mailing
IOWA CIN, IA
522462720
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
3/21/1992
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
-itation Dale Conviction Date ACO Explanation County JUR
12/13/2015 ;02/01/2016 S92 Speed Jasper IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
lccident Date Case Number
JUR
)7/30/2016 X933366-_ - ---T_-----. IIA
Sanctions
'ype Effective End ACD Explanation Occurrence JUR JUR
Suspended !05/09/2016 06/01/2016 'D53 iNon-Payment of Iowa Fine IA IA
Name: Daoud. Abdelgados Adll DL/ID: 769YY7191
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 be set upon this document, at Ankeny, Iowa this date:
•-Jj'If
IOWA .:tr'0.
8/20/2016
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Office of Driver Services
Iowa Department of Transportation
Name: Daoud, Abdelgados Adil DL/ID: 769YY7191
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. Criiu'ODLr)a3 ll� 001ry 11$.eCOIrd Check
Tn: IOWA - Division of Criminal Investigation
Support ®peratious $al'aall, 11, Floor
215 E. 7" Sheet
Des Moines, Iowa 50319
(515) 725-6056
(515) 725-6080 Fax
DCI Account Number: !{
(if app enable)
FI ora: C-9ity ofIowa City
City Clerk's Office
410 E. IWashitigton Servet
lova Cily,
Phone; 31°-3565041
Fax; 319-356.5497
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As of n , a sooroh of the provided name and date of Uirih revealed:
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No Iowa Criminal history Record found tvitll DCI
® TOWEL Criminal History Record attached, DCI
DCI
DCI -77 (08/25/10)
Received Time Aug. 15. 2016 4:30PM No,
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