HomeMy WebLinkAbout15-246j t IDENTIFICATION NO. S- wp
�w (Office Use Only)
APPLICATION FOR TAXICAB t MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY
(Police Department review must be made between 8 a.m. to 3 p.m, Monday - Friday)
410 East Washington Street
Iowa city, tows 52240-1826 Failr2re Pea comofEfe fhe�'re Meed'° information WPIf resulf in dental of fhe application
(3 19) 356-5040
(3 19) 356-5497 FAX
First T)'/v 1
1. Name (REQUIRED) r Middle V )C� Last
2. Address (REQUIRED) rAkd-5 �P, Ae l
3. Contact Information (REQUIRED) Email_ SD f f d rl /1/ 10 6.A � -��ell Phonei2
(All written communication ent via email)
4a Chauffeur's License expiration date (REQUIRED) 21— )"g -
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: &C C� _ j (ct
)
>J �wo -Y
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
7
What happened to the charge? (Circle one)
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
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other I
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _
Type of offense Where When
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please pro2fe the me
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE �E]RtIFIIM
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVEW
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
I reby serf at I have issued to me by the Iowa Department Transportation a valid Chauffeur's license number
issued on 22 -15 expiring on I understand that if I
falsely answer any questions in this application, that this ap lication 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 signedin front of a Notary Public)
Signature of Applicant J _,, I � — Date — 2 7 J /_�:—
STATE OF IOWA )
COUNTY OF JOHNSON
Subscribed and sworn to before me byS �) to }� 3� �� on this V,5' day of
`Qnt zip7C .
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 o l /ai
Signature Ooli i c—esignee
240(5
Date
AFTERAPPROVAL 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.
Signa qre of City Clerk or designee
Date
Office Use Only
Approved application
a
DCI report
G>–;
rQ
c i
State certified driving record
--t t–,
Website update
Nn...,..x'
CD
Ci_*
CIEs 7ARIDRIVBADGEAPPL92014amended.Doc
03/2015
')eP.LS. LU17 II:5Utilvl Ulv 0T t,rlm11al InveSIIgatlon N0.6/21 //5
From;Clty or Iowa CF1v Clark Oftica 31A 3666497 132/22/2016 10:46 4274 P.002/002
1 bin
STATE OF IOWA
C'rimival Hist,GrY Record Cheek
I
Request Farm
To: Iowa Division of criminal ineestil lion
support Operations Bureau, i" Fiooi
ZIS L I" street
Des Moines, lowt 50319
(515) 725-6066
(515) 725-6080 Fax -
me n,lnnda
AL
ate of Birth (nm loryl
61-6( — i9 62 -
Name
5 U /'7-A n/
DCI Account HmDber: '7Wa' F _
(irapplicahle)
Froll ClflovaCEty
CityityClerk's Office
910 L 1Vashin non 5trect
-lOwa�Cl, fy, iA 52240
P)one: 319-356-5041__
Fax, 319-356-5497
Olmale Drefnale
ataale fvatne
'D ArKA P,
Social Security Nutil
llS —7L� —1333
WUiver Infprinotion: Without a signed walver from the subject of the request, a complete crimhlal liklory record may not
be releasable, per Code of Iowa, Chapter 692.2. For co_ mglete criminal history record information, as allowed by law, ahrays
obtain a aa'alver signature from the subiect of the reauesl.
Waiver Release: I helcby give petnllStion for the about equesling official to coddocl on lova admiral luyloq record checl the Division of nin,ilfal
hrvealivalion (DCp. Any criminal hisloq• Bala cv��cerningpme than i; maintained t,y the DCI may be releaxed as allowed Ey law.
H'aiver Sig)xflure•
aor't'a Criminal History RecordClleck Results
As of9%�{,3�/5— a search of the provided name and date of birth revealed'
tONo lova Clil)tjnai Hislory Rccurd found with DCI
❑ Iowa Criminal History Record attached, DCI 0
DCI initials
Dl (06/25/10)
Rpreivpd Time Ser, 99 )HWIWI Nn AW
(DCI use all
ci
L:)
c;
0 G T
��..... VVVA,V iovtracot'gov
S""i.,EiIER. I tl" PL -i I CU:1O;; F (,'RI'VE'T, <.m ., .... . .
Office of Driver Services
PO Box: 9204 Dei Moines_ la 50306.-921,4
Pho+ie_ 515-244-9124 1 SC& -E32-1 ;21 1 fa,- 515-739-1837
wwW.lOwadot.Q9V
Certified Abstract of Driving Record
Inquiry Date:
9/22/2015
DL/ID #:
832AK7271 (IA)
CDL Permit Class:
None
Customer #:
6258171
Class:
D
CDL Permit Issue
None
ZIII�M- '—
Iowa Department of Transportation
Date:
Name:
Ali, Sultan Dirar
Audit #:
8327271
CDL Permit
None
Expiration Date:
Address:
2658 ROBERTS RD APT 2D
Issue Date:
08/06/2014
CDL Permit
None
Endorsements:
Expiration Date:
01/01/2022
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462743
Endorsements:
2
ID Status:
None
Mailing
2658 ROBERTS RD APT 2D
Restrictions:
NONE
OL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462743
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1962
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Ali, Sultan Dirar DL/ID: 832AK72,71
Page 1 of 1
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:
s. •""•• :1V N
9/22/2015
5
...... �`
Office of Driver Services
ZIII�M- '—
Iowa Department of Transportation
Name: Ali, Sultan Dirar DL/ID: 832AK7271
9/22/2015