HomeMy WebLinkAbout15-156IDENTIFICATION NO. i :Tj — , y
(Office Use On y)
CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
410 East Washington Strcct
Iowa City. Iowa 52240-1826 Faiture to Cornolefe the "reQuired" information will result in denial of the app7l%Cat%Ort
(319) 356-5040 � - —®
(319) 356-5497 FAX
Middle Lastrst /
1 Name (REQUIRED) �c'Fi11rzyrtPyl �j.p�,
2. Address (REQUIRED) 10,E Jc-& A, -e raj {I � �' .q �t
3. Contact Information (REQUIRED) Email: -2L4A_ 621f -J 11 ee A Cell Phone: Std -4�•a _ef2�"l
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) o 91 &412,„ e)
b. Taxicab Business Name (REQUIRED) f —
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this Statc—pr else ere?
Type of offense Where- C=en a ....
C"') -C t �--
What happened to the charge? (Circle one)
ry
Convicted Dismissed Deferred Suspended Plead Guilty �Otherca
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
When
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? /) L—
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
A �
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)
02/2015
APPLICATION FOR TAXICAB VE141CLE DRIVER
Page 2
I hereby certify thyt I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
x'14 r%f L57o3 issued ona o� g - expiring on oz zo, . I understand that if I
falsely answer any questions in this application, that this application may be denied. gree 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 oG o 2P(
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by Ill"AZQ_�Q A'nlC1IkC. on this - day of
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 Chauff u 's license _
4 �L
ignature of Police Chief or de-ftnee
zozb
0
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.
Sigirature of City Clerk or designee
�/
Date
N
O
Office Use Only
C?�
G -
Approved application
co-<
i
DCI report
M
State certified driving record
=
Website update
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cs
cc
Clerk/ IDRIVBADC,EAPPL92014amendedDOC
0312015
May 26. 2015w 4,17FM�lorDiv of Criminal Investigation os �o slNo. 8106P,P, 1/2 002
`YFg4�Frot4 STATE IOWA !,. i O44V.a
Criminal History Record Check
irvel, Requests •.0
-'�4�elAYafkrt��Y a '}
TO: Iowa Division of Criminal lnvesligatlon
Support Opel Ailons Dareau, I" t• loor
115 C. 7'l' Sti eel
Des Molnes, Iowa 50319
(515) 725-6066
(515)725-6000 Fax
19111 reoutstintr an Inwa Criminal Mi.elnnl Record Check nm
DQ AccounlNunlber:
--(if nppllrabk)
From: Clttof Iowa City _
City Clerk's office `..-- ..
410 L Washinglon Sireul —_
Iowa Cliv. lA 52240
1'110hc: 319-356-5041 _
Fax: 319-356.5497
]Last Name (nmitlzrop9
First Name (mandatory)
Middle Name (jecomyc,ldcd)
Add t�
1 1011-ame��
KU 6aymt c
Date of Birth (manaalmy)
Gender (mandmory)
Social Security Number (rtconimended)
Iowa Criminal History Record atrached, DCIrTl
Ct
oz/a/� I/�f',e
❑ren,ale5'�
6�- 50 0
Waiver Information: Without a signed walver from [Le subject of lbs request, s complete criminal llstory record may not
be releasable, per Code of Iowa, Chapter 6912. For comlAct crlmhlal history record informallon, as allowed by law, ahva),s
Obtain a lraiyer signature from the subject of the re hest.
Wai veP MefeSe: 1 hereby give persuasion for the above requesting official to conduct an Iowa criminal history record check with the nNisioo of criminal
IOVeSliga[iou (Dery Any Crim ill al hiStary dsto conccraing me lhal is main rained by the DCl may be released as allowed by law,
Waiver Sigrurlur•�---
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(UCI Ilse only)
As of _- '�5 1 a 1`40 1,r , a search of,he provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
c"
Iowa Criminal History Record atrached, DCIrTl
Ct
UCI initials- fv--
N
,CG7
DC147 (08/25/10)
r—'r a
Received Time
May.22, 2015 2:55PM No. 0760
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Office of Dtivet Services
PO Box 9204 t Des Moines, to 50-106-9204
Phone. 615-244-IM24 i 800R532-7131 I Fact. 51--239-1837
WYrw }owaab`i..Lj6V
Certified Abstract of Driving Record
Inquiry Date:
5/22/2015
DL/ID #:
874AL5703 (IA)
Name:
Abdalla, Mohamed
Class:
D
Address:
106 15T AVE
Audit ir:
9072752
Restriction
None
Issue Date:
05/09/2015
City/State:
CORALVILLE, IA 522412602
Expiration Date:
02/24/2020
Endorsements:
3
Mailing Address:
106 IST AVE
Restrictions:
NONE
Date of Birth:
2/24/1976
Mailing City/State:
CORALVILLE, IA 522412602
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Abdalla, Mohamed DL/ID: 874AL5703
Customer #:
6311770
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
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 usiodiao of the records held by Lie 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:
5/22/2015
IOWA
).0.T. S.
r'9ANES Office of Driver Services
Wf �% Iowa Department of Transportation
Name: Abdalla, Mohamed DL/ID: 874AL5703