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HomeMy WebLinkAbout15-143� � t t.rw �:r me irl CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX IDENTIFICATION NO 15-iq (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 First Middle Last p ' 1. Name (REQUIRED) __i 1 i >I3p F� in isiE�P M ol�A nF7 R �- 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email: `<ocK M�(� q ��` _ «tom Cell Phone: _��2� S� All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) cel - _ 7 7Q b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? — Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where Vhen 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? 1. 1 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) �c�lwlvvf�o GSR Lia r%?.. _ 1. ,-nil DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICAT ION 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 VEHICLE DRIVER Page 2 4'63/ FP I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number �J�F��ied on _2\- \t expiring on e(-ol- 7jz]r I understand that if I false y an 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, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date S l xxxzxi.....e ** xxxxxx;u;F3i* STATE OF IOWA ) COUNTY OF JOHNSON ) I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code). Signature of olice Chief designee 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. THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR. Signat e of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update 7/4 e' 115 Date Ul-r l H IDRN6ADrFAPPL92014.m,„ded.DOC 0212015 Wage 1 of 2 g 1: ', 4 1i i,- #A00T yvav�nr imadotgov 5':iflR'tF ! _•,;}°Lf' E CU>TUMtR DRIVEN--- -- - Office or Driver Services POB11- '+?0.A _ Des Moines, IA 50 30 6-0 210%4 r'Rof 575 V4.ur2l iRAtt-532-A F21Ifax. 515-239-18?7 b-w^N i0wadaat tr'7Y Certified Abstract of Driving Record Inquiry Datet 7iii2olS DL/ID At: 461AP2313 (IA; Name: .Ai7, "Idgoi Abdeknageep Class: D CDL Med ti; k.imrc Status: Address: 16i, ABER AVE M I ii Audit #t 9103552 Issue Date: 0511112015 City/State: IOvyA t'IPY, IA Expiration til/oi%9020 ,. 14 11! Date: Endorsements: i Ma0mv Address: 1631 ABFif AVE APf R !Restrictions: Nt?NE Date of Birth: 1/1/1980 Marling City/State: I(?Wc CITY. IA Sex: M 522464729 History Information Corivictinns Customer At: 5747657 ID Status: None DL Status: VAL CDL Status: None CDL Cert None Status: CDL Med None Status: Restriction None Supplement: .ACD Explanation county 7iiR 4/'c' It 08/ib1201)S9Z Speed Johnson IA 1 Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. N„rntr er 3Dg IHi 2i;% 111411 Name: A4, ADdeiniaq<:eri Muh�mec DL/ID: 463AF 2313 tOr^,uan1 to Iowa Cride 5021.110, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportatlon,, do hereby r.erhfy [ria[ ! am the custodian of tbe. records held by the Uthce of Driver Services, that this is a true and accurate Copy of e. rr cfaGe' record r;urreri'y v+ the custody of said office, and that t have been authorized by the Director of the Iowa Department of Transportation to so certify. in wncess wherrot, I have caused my -ir, noir, rC and the seai of the Deparunent to be set ;q:en this doc°.,nrent, at Ankeny, Iowa `Ila date 7/I/20IS : 0. 0. T ty�'•. '4? ✓IAIIFt• Gfffre of Driver Services 7/I/20IS 00 a Cc rlr.-ore fi �. irvp .__2/00 v f ATE OF 10VVA Criminal Higoryr Recox-d f,he(:k Request Form lv. lairs l!lafna'l kit 1, Rp isi 4l lnst;f iKa Unr\ �upporl Cperelions hurtbu, I" P{ool 2t52. 1'[ Ttrod Liss Mtinnr., Iowa 56339 (.515) 735.7:065 {515; 725 608@ Ret act ;JCI Ac2owd Nuwher 7" +otbr xtie/... I>ronl: C7Iv ul lorn?-lit_ _ 410,SJreal laws Clly, IA 52246 Phonr. J19.356-SOaI Fs e; 319-W-6497 ;O1Y;2111e man!!"'6'___.__. AIA (310 1 ndot (nanmle.� —Y` Tale ©Femfale IH e A8P Cl.M/-c"`iet:o MOKAMp -il'06i'£Y Xl71ff2YYAf1lfOtl: iV(ltlarlt A slI ltd .i'af er tram the SuLf tct Who re4 nest, s cmnpic(C crlminsi hiSlO ry racntd mop not 4e releataLic, per Code of lairs, Chspler 692.1. Fet car_ ncicle crimbul It Oster), i ecord Into rmation, a a11"vil by let+', sin jy3 II�(lli'Ql'a'ZiiiflS4 ,tCrccy yLlptnriirien Taj L-[SDwiia 1p5tidf;w vu Hl iC,s,[nna PlNiiSlPry 7aa4 d.E[i VitR IhF Uil;IIen af�rldlixal i i..[6got14P (D�11 Kay u3ny !! Wap, del, t It'n 1p mrihl! (arlH[ 11Cl nJJ 3% al,wa ik eGesxE yyiom lS nn tr j'jgatnrtl! c Q ladnai History Record Check Results As o#'__� =' , a search of Illy, plcvidtd name wad date of Cirih revealed: r LA /1-71 hlt: 1on'a Cuinu;nl 1-l410,yAccuid (ovYld.,,ilh fJGI to .,; -- r'yl L] iflA,J ,"rifrina! Flis(01V Reeved muchtd, DCl — — — x i D(1 irDi(i>ti°„_ r N =re,vtl ?ic:c Jo`1 ?015 11:HAY, No 9166 K=ieived 1Yq,n ,lun 17. 2t)I; 1:00('N No, (i9l7