HomeMy WebLinkAbout15-056wr:
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-S497 FAX
1. Name (Ilelii a"YtVVII N fll?;(
?. Address (RlirtgD0018',;D)
DENTICAPONdV NO, IS
(Office i,.Ise Orally(
APPLIICA'B"VON FORTAX11CAB / MOTORIZED IPE DIICAB VEHICLE ORPIER
(Pollice Department ireviiew must be made between 8 a„imn.. to 3 p.m., Monday -- Friday)
3. Contact Information (II E tU N ,V; D) E"maii:
IMiddie
l /iir /If J"',, ,, f� a Yl,i i-7 J�Yf i+ll I/f
4a. Chauffeur's License expiration date Qit?il',„U.UVVdII i:D)
.............� .........
b. Taxicab Business Name (i l a»,V.DIIII t 11 r) j q.
6. Prior experience in transportation of Ipasselmntois. ............................... ...” ,C,V c
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
:ype of offense WhereWheeAR (i 2615
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?
.Nype ra.(..pfiiep se ry)P9hwe When
.....2 "......... V....0.3
...
Wh- t tta eraa:d rat the Charge? Ciircie one) ok
Convicted Dismissed Deferred Suspended Plead Guilty Other d
8. Has your driver's license or chauffeur's license been suspended or revoked in the Vast five; years? . L A
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
IDEPARTIVIEN'f OF CNIIMIINAII.. iNVESTIIGATDON (DCQ REPORT AND STATE CEIB'T l IIEY.'D
DR1ViNG RECORD IRAUST ACCOMPANY'THIIS APPLUCATNON FOR POLICE CHiEF REVIEW
You must apply ffou an individuM Department of Criiimniinall Nnvestiigatiion report (ffonn avallablle iupon request),,
(SECOND PAGE i'OR REO,UJIIRED SIGNATURE AND NO"i"ARY)
02/2016
A1�4'AIMMA"I"101 M IFOR "'II"AItIICAIB Aliiii!I"'IM0i..IIICm'i IIIDIRIICf'?JI'F:
IWja 2
I herl c rtify th I have 'ssued to me by the Iowa Depa ment of Transportation a valid Chauffeur's license number
" Cil D ' c issued on ��ex�ring on N% J&z a � I . I understand that if I
falsely' newer any questions in his application, that this appli ation maybe denied. I agree that in making this application,
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 AppficaMB..................
STATE OF IOWA )
COUNTYOFJOHNSON )
before me by
on this 62 "k � day of
�ttVma w U i � ira'iPac i XdAn9'�98� ll, "✓F° . U" � n"k",. M � � "� ��°° 9�:
gamh rga l"ulUb c lin and Esau the State of Uowa
' Y ♦ �k Q11 OR . 00 1
.r u
i# 4 r47'w1#fliZj f l
Signature d'f P lice iF, or designee
.........................................:m
Tate
AFTER APPROVAL IBY T14E CITY CLERK YOU ARE AUTHORIZEDTO IDRIIVfE A, TAXICAB IIW (IOWA CITY FOR NO
MORIF. THAN ONE YEAR l::ROM TNIE DATE LISTED BELOW..
THE EFFECTIVE DATE Wlt.i_ IVA'TCH H E CHAUFFEUR'S UIICEIMSE IEXPII Pl01M IF LESS THAN A YEAR.
Signa u�re®of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
HAR c 206
a*riarw«DRNBADGEArrL92Of4am Wed.00c 02/2015
Mar. 2. 2015• 4:12PM Div of Criminal Investigation
...•L,• cv 1) J, 7 J - M v,,r vi cra vi sr vi sutra vi L
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STATEOF IOWA
Y
Ifi , ,zr (CriminalRecord Check
Request.1.. ,
ti
To, Iowa Division of Criminal Investigation
Support Operatlone llumau,1" Floor
21S E. 91b Street
Deg Moines, ie WA 60319
(515) 725-6066
(515) 925-6080 flax
Record Check on.
No.1480 P. 5/6
IN.7 1. )
DCIAceountNumbev: zfo®2'V'-
orapplleable)
FraIR', ✓'it ofX6PW �.
City Cierlceg Office
410.',3, Washington Street
POWs Clty, Ifs. 52140
phones 319-356-30411
Max. 319-336-3497
ala OFemale C 6 `d 6� 2 —7-4-C
Wtfftl'dp'.FU(fesrmartim Without n awned Valver farom the subject of the request, a complete, or9talnod history record may trot
the rehatsable, por Cade oflowa, Chapter 692.2, For jaw—lft arlsninal history record Information, as allowed by law, always
Watmor Release: I hereby give pvmkslon fit the ®boyo regaestingofctal to eonduot on Iowa criminal hisloryrecord cheek ryllh the Division ofOrIminel
rnvcsdgallon (l)% Any criminal hislory data aoneemlng Me [hath maintained by the DCI may be releated as allowed bylaw.
As of a -search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with ACI
F1 Iowa Crirninal Iiistary Record attached, I)CI
t)Cl ° "tial®
rrrt7 nantn0-i
Received ime eb.21. 2015 3:47PM No. 1415
(DCl use only)
DOT"ms I VI' I
44
ARTT��..:'f . :d
�WDMANNOAMn�oNJlh 06�(F F�eROFAlliL'OVNOItt011WWM06
office of Dimer Services
PQ E9o'. 9204;. Dos e'+s`°- _....K 50:a*t5-srR:N
€'hc: e'. E15 -244-9f24; h.3,:. -..:2'f ; 7a.,-- Fv5-219_1637
t4tAY�Tt.d'.Y:k G gav
Inquiry Date:
3/5/2015
Name:
Ali, Samir Isameldeln
Address:
2427 BARTELT RD APT
CDL Status:
213
City/State:
IOWA CITY, IA
Status:
522462710
Uy r
DL/ID #: 266AD7808 (IA)
Class: D
Audit #: 7504999
Issue Date: 11/06/2013
Expiration 11/03/2018
Date:
Endorsements: 3
Mailing Address: 2427 BARTELT RD APT Restrictions: NONE
213 Date of Birth: 11/3/1985
Mailing City/State: IOWA CITY, IA Sex: M
522462710
History Information
Customer #:
5429309
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert
None
Status:
09
CDL Med
None
Status:
01/28/201.
Restriction
None
Supplement:
;
Accidents - Accident involvement indicated doe
pf :t t,_ C': k flulrsainaitr ''&kAC'",
Name: All, Samir Isameldeln DL/ID: 266AD7808
Pursuant to Iowa Code §321.10, I, 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:
C:.t:Eii IBIS
IOWA �:�
!. 0. T; 3/5/2015
II r
AO/J15/2009
Johnson
JA
09/09/2009
09
' ,..'Johnsonx
01/28/201.
0 0 01
'Improper Parking on r a
Johnson
;
Accidents - Accident involvement indicated doe
pf :t t,_ C': k flulrsainaitr ''&kAC'",
Name: All, Samir Isameldeln DL/ID: 266AD7808
Pursuant to Iowa Code §321.10, I, 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:
C:.t:Eii IBIS
IOWA �:�
!. 0. T; 3/5/2015