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HomeMy WebLinkAbout15-245CITY OF IOWA CITY 410 Last Washington Street Iowa Clty, Iowa 522 40-1 82 6 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. )i5---Z—L/5- (Office 5—ZL/(Office Use Only) APPLICATION FOR TAXICAB 1 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 2. Address (REQUIRED),,2.6c;L 2, Y1- JL) ff%T C / cn` ' t C+ LIJ TA �,z� 3. Contact Information (REQUIRED) Email: Kctctn'mow t%�ic�-a:f,c' Cell Phone: 2e-)l-�33"O9Ry (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) C,6 / / b /2(.1 ( b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers, A vyzY i c uX L v 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? ,N 10 Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plpar+ r , Other 7. Have you been arrested / charged with any traffic offenses in the last five years? 91 Type of offense Where When scMfle c,:4' V- ZS i.. 4LI ��i�ke.� jhy 5v v Z-3 �O✓"\ i �R- ova r 25 7,C -red ',J -e4- Toh-'i"^. C4.�--.Z,-� j� /}�J,-, L;-! -t_o I What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspendedead Guilty Other 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 be an Iowa City taxi driver using a different name? If yes, please wide 0 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA71:qr.:FR IED — DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLIO MEF RREVIE You must apply for an individual Department of Criminal Investigation Report (form avaljabfe r&pn re t). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) w 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I��ve issued to me by the Iowa De artment of Transportation a valid Chauffeur's license number 3 jq' �f issued on 0 jZ,expiring on a` Z�/ I understand that if I falsely answer 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/0 i 5 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and swor to before me by _ KrA%x tI �, rvU_k -t . on this _l,�__ day of 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). j Expiration date of Cha e is license o\Z 10 2OfS� Signature of Police Chief oYgesignee I Dat 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. Sign of City ler c or designee Office Use Only Approved application DCI report State certified driving record Website update �0 V1\\n Date Lle,kFfMDRN6ADEAPPL92014.m.ndeI.UDC 03/2015 Uci. 9. ZUI 9:IJAM 0 1 v of UrimInaI Investigation No, )684 F. 1/1 F1.,,—ny u, ,,y Clerrc ...1l', 10/02/2016 16:6. 0280 r,u�2/QCZ STATE OF IOWA Criminal History Revard Check Request Form DCI Account Nuniber: t r (if applicable) Ta; Iowa Divis(mtofCriminal lnvestigatlou VC0111: CltvoffonuCity _ _ Support OperatiuosDureiiu,J"Floor City Cleric's office 215 E. 7" Street 410 C. 1J€rashington Street Des Moines, Iowa 50319 (515) 725-6065 Iowa Citv (515) 725-6080 Fax -- ------ Phone: 319-356-5041 I7ax; 319-351 1 fill' re uestm an Iowa Criminal History Record Check on Last Naltle (11181)dA(a ) MrSt Name (m andatory) Middle IValne (recoamtonded) fl/� GIS. fzt {err �CCd inter -f f> 64 Bate of Birth imandawry) Gender (mandalory) Social Seculi Nnniber (reeolnrncddea) �Cr J � �' �r��'G� ®Male ❑female ����- �'Ga ��tC� Waiver Itlfbrr»ntion: Without a signed svafver from the subject of the request, a complete criminal history record may nal be releasable, per Code of Iowa, Chaplet 692.2. rm' coni criminal history record information, as allowed by law, always oblain a waiver signature from the subiect of the reouest. Waiver Release: I hereby give p:nni55ion for the alcove requesting official to conduce on Iowa criminal bislory record check wilh the Division orCfloiloal f nlesligolion (DCI. Any rrlminaI h [story dale concerning me that is maintained by the DCA may be released as allowed by jaw, Waiver Iowa Criminal Uktory Record Check Results As of —. V -5 —is u, a search of the provided Aiame and dale of birth fev,ealed: K No Iowa Criminal Histor3' Record found [kith DCI ❑ fo\va Criurinal History Record attached, DCI # DCI inihals W ucd-�i (ua�z�nu) Received Time 00 2. 2015 2'.§9PM Mo.9432 5 (DCA use only) Iowa Department of Transportation r ,#cflk I m'(- i 1;,7i 1.4ks 4 9-iJ 1.1 4 ; 1 X `_.1 Jr7 'sl Convictions Citation Date Certified Abstract of Driving Record Ex lanakion Inquiry Date: 10/2/2015 DL/ID #: 733AJ9154 (IA) Customer #: 6142527 Name: Mustafa, Kamall Class: D ID Status: None Eldien Address: 2602 BARTELL RD Audit #: 7349572 DL Status: VAL APT 1C Issue Date: 09/17/2013 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 09/18/2018 CDL Cert Status: None 522462727 Endorsements: 3 CDL Med Status: None Mailing Address: 2602 BARTELT RD Restrictions: NONE Restriction None APT 1C Supplement; Date of Birth: 9/18/1975 Mailing IOWA CITY, 1A Sex: M City/State: 5224b2727 , History Information Convictions Citation Date Conviction Date ACD Ex lanakion Count JUR DS/23/2U 14 09/04/2014 S92 Speed Johnson IA 10/05/2014 10/16/2014 S92 Speed Johnson IA Name: 'lustafa, Kamall Eldien DL/ID: 733AJ9154 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: N j_ �il<IC["•t, 10/2/2015 -tt d 211 —4 �/'yy}..13 ;fsr # F d s ©. D. T � �==fir, ,� -��, s- ''• Office of Driver Services Iowa Department of Transporation 'n