HomeMy WebLinkAbout15-208rlalll �
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
119) 3S6-3040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. %5-- �I-f7
(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
r
Middle
2. Address (REQUIRED) �Ls 12- AS,-fe r ft V e-- ac S a
c .
C-0
3. Contact Information (REQUIRED) Email:
P
(All written communication sent v email)
4a.
It.
5,
Last i 1
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
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? #;—
Type of offense Where When
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? Q Q
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please i
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA -
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE
You must apply for an individual Department of Criminal Investigation Report (form avahi urn recp172t3t).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) W
cn
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issue�to me by the Iowa De a ment of Transportation a Valid Chauffeur's license number
Li �t ZZ�j 3 issued on Jil-i4ito,4 expiring on 69 q I ?c,,5 . I understand that if I
falsely answer any questions in this application, that this application may be denied. I a ree 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 U / l 14� -' DthL4,> Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by _QLAy.^0< 1 on this L day of
c_ n -ll" _)^t�
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 69 13 ? 4I
Signature of Pollbe Chief or designee
o90 lS
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.
Aignae of City Clerk ordesigRee
9 � /
Cate
Q�
ra..;
GJl
Office Use Only
v
Approved application
C
DCI report
„
ZZ
State certified driving record,
c?
Website update
w
cs,
cierwrnxiDRiveaoce PPL9201a mended DOC 0312015
r—nAllg,13 2t)1§, 11115 A MCi er i N l v c' Cl'Iminu.l 1n V e:l le3t l op Cet/12/2016 0e:4No' 222.22aa1'.. 2'_2 rooe
STATE FBFIOWA
Crin-tinal History Record Check
Request Corm
TO: Iowa Division of Criminal Investigation
Support Operations Ciurra u, i" Plour
215 E, 7t"Wool
lies hAoiaos, lolaa 50319
(515)725-6066
(515) 72$-6080 Pas
An'rcyuesling an Iowa Crilminal Histo Record Chi:6
Last Name(„andmory) I Mrs tName
— L -e `. --� (�' I rI1JM21e
DCI Account Number: --�1-
(fapplicablc) -
City Ctcrk's office --------
416k. Was non Sh•col
iovia CiIXI 1A 52240 — —
Phone: 319-356-5041
Pax; 319.356,5497
❑Female
e
Waiver Inforntatiou: Without a signtd waiver from the subject of the request, a complete criminal hlsiory record may not
be releasable, per Code of Iowa, Chapter 692.2, r"01-011111210 crirninal his(ary record hnforma(lon, as allor'ed by larv, ola'a)'s
obtain s a �aival•ela..�no•:. rn...., 11--.r.:__: _e.I---____•
Waiver Release. I hereby give pertltissiwl for the ebovc requesting official to wndvcI sn noxa criminel hisloq receld check �Ofi me Division ofooriminsl
Investigation (DCO. Any criminal history darn coil cem;osme Ihal is miolainedby me DCI maybe I-Imcd as allowed by law.
Waiver Signature:
D r fi1Z
Received Time Aug, 12, 2015 9:36AM No, 2644
Ima Criminal HIston, Record Check Resutt$ �
�
(DCI usa only)
As of--
i ILU�, a search of the Provided flame and dale of birth revealed:
No Iowa Criminal History Record found with DG
r"
--El
lows Criminal 1-lislory Record attached, L)Cl II
DCI initials
`
DO.77(08/25/10)
—�—�-.._-----
Received Time Aug, 12, 2015 9:36AM No, 2644
C 404 . Id
4610WADOT
ww,iowadot.goy
5 t AFTER 1 <IMPILLR i CUSTOMPF DRIVEN
Office of Striver services
PO Box 9:.04 j Des Moines, IA 50306-9244
Phone: 515-244-9124 1600-5,32-11211 Fax- 515-239-f837
www_owadol-gov
Certified Abstract of Driving Record
Inquiry Date:
8/12/2015
DL/ID #:
434ZZ5639 (IA)
Customer #:
2959537
Name:
Diallo, Oumar
Class:
D
ID Status:
None
Address:
2512 ASTER AVE
Audit #:
8473941
DL Status:
VAL
Issue Date:
09/24/2014
CDL Status:
None
City/State:
IOWA CITY, IA 522406733
Expiration Date:
09/17/2D15
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2512 ASTER AVE
Restrictions:
NONE
Restriction
None
Date of Birth:
9/6/1970
Supplement:
Mailing City/State:
IOWA CITY, IA 522406733
Sex:
M
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation _
County
JUR
07/30/2011
08/03/2011
M14
(Fail to Obey Traffic Sign/Signal
Johnson
IA
Name: Diallo, Oumar DL/ID: 434ZZ5639
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:
;........ :"�/'1
8/12/2015
IOWA•.;
D. 0. T.Zi
C40-0
r
9f'•••••@"$�'
Office of Driver Services
11,881
Iowa Department of Transportation
ry
Name: Diallo, Oumar Dli 434ZZ5639 0