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HomeMy WebLinkAbout15-176`r 1 _fit `IIIMtp� WA rzCITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO._/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 First 1. Name (REQUIRED) 2. Address (REQUIRED) / $3 7 J /.�f 3. Contact Information (REQUIRED) Email: r 5 rn 4� C� �rnstuX Cell Phone. l y�/,(!j (All written communication sent email) 4a. Chauffeur's License expiration date (REQUIRED) !©g/2 i .`10 / s— b. Taxicab Business Name (REQUIRED) TO v-,x,r k 'TaXL 5. Prior experience in transportation of passengers: _ . ;�� i n -c? �GLa' i 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 00 Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where I _ 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? 8z Tvpe of offense Where When l":3 crr k]d& N 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provade+the-w U iz DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT EERTIf6hD DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RVIEIM 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 I hereby certify that I have issued to me b the Iowa De rt ent of Trans or: tion a Vali Chauffeur's license number 7'7 z 6 8 3 y y issued ona o 21 / expiring ,r �% G 2o) 1 understand that if I falsely answer any questions in this application, that this appli tion may be denied. I 'agred 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, Chester 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant % Date d STATE OF IOWA ) COUNTY OF JOHNSON 1 Subscribed and sworn to before me by 5 u �c I ` ROLL . iU P c_0 on this V-� day of saw WENDY S. MAYER r 729428 Notary Public in an or the State of Iowa mi Commission plres aw —7-a �� L.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 Code). Expiration date of Chauffeur's license Signature of Police Et 1f orV esi� gnee 'D to / � 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. Snatuxe of City Clerk or designee Y, , / �/5 Dante ClerkrFAXIDRIVEADGEAPPL92074amended.DOC 0312015 Office Use Onlyrj �.. Approved application rei FTI DCI report State certified driving record — w Website update - f- ClerkrFAXIDRIVEADGEAPPL92074amended.DOC 0312015 *4iU%1%kD0T WWW SMsaFFk I <f 4P `:R I CUSTOMF, DRIVE! iowadotgov — Office of Driver Services PO Box 9204 ; Des Niolnes, IA 50306-9204 Phone -515-244-9124[800-532-1121 1. Fav 515-239-1.837 wwa7.iowadert_gov Certified Abstract of Driving Record Inquiry Date: 8/19/2015 DL/ID #: 775ZZ6832 (IA) Customer #: 3874967 Name: Mohamed Bakheit, Ismail Class: D ID Status: None Address: 1837 GRYN DR Audit #: 8317464 DL Status: VAL Issue Date: 08/02/2014 CDL Status: None City/State: IOWA CITY, IA 522464406 Expiration Date: 07/04/2019 CDL Cert Status: None owa Department Endorsements: 3 CDL Med Status: None Mailing Address: 1837 GRYN DR Restrictions: NONE Restriction None Date of Birth: 7/4/1959 Supplement: Mailing City/State: IOWA CITY, IA 522464406 Sex: M --f i History Information Convictions 1 Citation care Conviction Date ACD Explanation County 3 U a 09/08/2013 03/27/2014 N82 Improper Backing Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. i1cddent Date Case Number Jug. 09/08/2013 _... _. -756111 IA 11/22/2014. -:830163 _ IA Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832 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: IOWA'. D. 0. T. s' I'�,i®�8�$IOff of Driver eof lTransportation owa Department CC, =.3 C Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832 --f i 1 .r Au'g.21� 2.015 9:15AN Div of CYIminaI Investigation No. 3709 P, 2/2 Fr_-.,. I .— — , CIPr.. ____ — -— —__— - 08/10/2016 lion— d224 1,VV2/002 STATE OF I OWA CHniif-fisttll-y i�ect)r(i C;f1ecEt G)l ReqwstForin To; inwn Divlsium of Crinlfual Uweslipfiam SUP PON Qperotlonu liuroeu, 1,1 Now 215 Z 711j Street Des Maine$, lows 511319 (515)925-6066 (515) 725-6080 1,,2x 1221 requesting; an MoM.�«,.� B 16:� A�z Gen fKA Accotnll 1\4unb6r: 14oQ,;� —v fif applioeEle) -'-�- From;Iowa Clly Cfel'If's _ 410 L. W ash ingtpn 5'ttdet fuls•a City, IA 5224(1 Pboue: 319-3S6.5041 `ry� Par: 319-356 .__ aVClal A8ellrl � Nltm bel fecamrnendcd ❑Eemate 3 I - 7g— o /47C '""Y" DIVOT 1700YJd With vu( a signed,, aiver 'rom the subfec( ofthe request, a complete criminal h)gtvr�, record mAY not be releasable, per Code of Iowa, Chapter 692.2. For co_ mblete criminal history record information, as allowed re tan•, alw&ys obtain a waiver si netu re from the sub tet of there ucst. _ WftiVer Re/ease; I Immby girt permission for the 31i,t rtgnesling effmisllo canducl m larva criminal his)Oty reoold citaq rvl@ bit I)i� ision ni ctim"') Int' 5301100 (I)C1), Am) ari4llllaI Ilinary data cosec ming nu )hal is mam iaincd bylilt t1CJ maybe relewA ni allmved 11'aivel Signature faWa Criminal l istor ' Recot-d Check RZesait5 p)Cl nae cmy9 As of � a search of the 1)"Ovided flame kind date of bil1h ='= ul Nn lona (;liminal history Record fuund with 11(_11 L� ' (� Iowa C;rintinal )iisloly )ZCLOr CI attached, DC) N r- 00-77 (08/2VIO) Received Time Aug. 19. 2015 4 04PN No.3559