HomeMy WebLinkAbout15-186CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 35 6- 5040
(319) 35 6-549 7 FAA
IDENTIFICATION NO. l S` 1 Bto
(Office Use Only)
ill-�^)I Lr
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 decrial of the application
FirstMiddle Last i '
1. Name (REQUIRED) A ti i; ,\ ( Asp � M �(rEep M o4AmFp JAt L- I
2. Address (REQUIRED) I �AV e_ *9
3. Contact Information (REQUIRED) Email: )<ccitC M 0 ZQ �j Cell Phone: 3t
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 01 —
b. Taxicab Business Name (REQUIRED) _ ! c7<< V\ Cti kj
t
5 Prior experience in transportation of passengers: 1 �,�,+ o Pw t e c Y K .ate
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? h
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 hen
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? IN t2�
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)
\ i d i M A, e r n k, r , r-> t_ - NJ -\
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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
qG3�Fz3�3
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
L z = 2 died on r,—Z1—\ C expiring on i,� I - o 76 I understand that if I
farse y answer any questions in'his 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 20 j.7 _ Z e S
STATE OF IOWA )
COUNTY OF JOHNSON )
Sub 4;pbed and worn to before me by j� on this day of
' e&A, KELLIE K. TU
TTLE - t /�- �L�
n er 22tats otary Public in and for the State of Iowa
My
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).
Signatre ofof Police Chief or designee
.k*; -1/20/ (s
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.
If.,
SignatiNy,e of City Clerk or designee'
Office Use Only
Approved application
DCI report
State certified driving record
Website update
714 IC51 //S
Date
a«ti7faiorii+ BAOGEAPPLe2oiaamended.Doc 0212015
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1 A E OF IOWA
r ,_) Criminal History Recox•d Check
Request Porth
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Iowa G iaaainai. History Record Check Results
As oi'__,�q♦1 , e match of the provided name and da(e of birth reveliled.
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U lila History Rcu,,sd rltacbed, DCi#
DCI imliin.is. _PI
DC1 77 (w,125110)
rtas,v¢d iimr Jun_i1. 2015 11:08AN No. 9144
Tfgi/ Jun 11. ?111J u00pV No 9911
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WWW.i0wedot,gov
Ski A0LY I ,Imj"�IP i CUSTOMER DRIVfN..x..:� �...
Office of Driver Services
PO Bo= ''?01 hies Moines, IA 5030E-92014
iT,,ini- `.. 75 : 44.412J' P 0t ,3:-15211 f'a+.525-239-18?7
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Certified Abstract of Driving Record
Inquiry Dated
7;1JJf]l5
OL/ID #:
d1»AF7313 OA;
Customer 0:
5747667
Name:
At,, IdaVl Abdeh,iauee;+
Class:
D
ID Status:
None
,..1,-.1111C.I
Address:
363r AELk AVt. A?`I ti
Audit 9:
910:fYY7
DL Status:
VAI.
Issue Date:
Os/2 W201 s
COL Status:
None.
city/State;
!fIV44 CI IY. TA
Expiration
{rI/QI/ Wo
Cot- Carr
None
,... ,.. ti15
Date:
Status:
Endorsements;
3
CDL Med
None
Status:
Mailing Address:
ih+: AW -R AVI AH b
Restrictions:
NOW
Restriction
None
Date of Birth:
1; li 1980
Supplement;
Mailing City/State:
If;A) t,:IIY, IA
Sex;
M
522464729
History Information
Convictions
I ^.,t=i. imrvu.trun ntte ALD Explanation County ]t]R
, n7il4/2GI2 08/16/1017 591 Speed 3ohnson IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
-Irr,. , f ,,,, tate Nomher JUR
IN12C i 111412 IA
Name: -N,, Magd. Aodelmagted hlohamer, DL/ID: 463AU2313
fr;isuant to Iowa Cnde gi21.1o, I, Kim ;nook, Director of office of Driver Services, Iowa Department of Transportation, do
hereby certify mat I am the cocioolan or the records held by the Ufbce of Driver Services, that this Is a true and accurate copy of
an cfficle' record c!rrcriVy i, the custody of said office, and that i have been authorized by the Director of the Iowa Department of
I ransportabon to sn certify.
In mlr.ess wherr,t, t have caused avd the seal of the Uepartrnerd to he set uhen this doa,ownt, at Ankeny, Iowa
thrs tlTte
gfflc,e of Driver Services
7/1/2015