HomeMy WebLinkAbout15-240CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 3S6-5497 VAX
1, Name (REQUIRED)
2. Address (REQUIRED'
3- Contact Information (RtUUINLU)
IDENTIFICATION NO. ( —
a— 2yn
(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
tmail: am,n a(focchcy7v�yma;�-rte+Cell Phone: 5-1 2710&66
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State &.1gl5ew&e?
Type of offense Where
ry
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4--1 -1
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
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Other t-
When
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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 nears?
Type' of offers
Ae
Y o
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)
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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
I he"
b certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
6D 2 � ) .Lf - ! issued on c5-7 015 expiring on C)'f/ oS/ / 56 . I understand that if I
false y 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,Ch� 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant J Date L)
l
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribedand swsrn to before me by Ait r ,2 - �} Xid l5a_ � ,cam on this 2-1 day of
_nom 7n / _1�
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 'T 15r io! (/
Signature Chief or designee
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.
Sign of City Clerk or designee
'�-1 I I1�-)
Date
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Office Use Only
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Approved application 1 [f
DCI report " ry
State certified driving record r
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0312015
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WAFER I f !"i Fl-4 I t.�'t�}�rJ._� DFAIIEN® mss.: ...,.ate.— � aswa.m w
Office of Driver Services
PO Dor 9,204 Des Maines. 1 Q306-.204
306-9204
Pha^c 5i5-244-9124 i ECC-532-1"21 I F3:v: 515-23v-1£37
Certified Abstract of Driving Record
Inquiry Date:
9/29/2015
DL/ID #:
673AJO477 (IA)
CDL Permit Class:
None
Customer #:
6068081
Class:
D
CDL Permit Issue
None
09/20/2015
09/24/2015
S92
Speed
Date:
IA
Name:
Ibrahim, Amin Mohamed
Audit #:
9066622
CDL Permit
None
Adam
Expiration Date:
Address:
2420 BARTELT RD APT 2C
Issue Date:
05/07/2015
CDL Permit
None
Endorsements:
Expiration Date:
04/05/2018
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462707
Endorsements:
3
ID Status:
None
Mailing
2420 BARTELT RD APT 2C
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462707
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
4/5/1968
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
06/18/2014
07/07/2014
S92
Speed (10 mph & under in 35-55 mph zone)
Polk
IA
09/20/2015
09/24/2015
S92
Speed
Johnson
IA
Name: Ibrahim, Amin Mohamed Adam DL/ID: 673AJ0477
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. 0.1
Name: Ibrahim, Amin Mohamed Adam DL/ID: 673AI0477
9/29/2015
R,/�
Office of Driver Services
"rc,�f�
Iowa Department of Transportati�°
State of Iowa
Division of Criminal Investigation
215 E. 7`n Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 5151725-6080
Iowa Criminal History Record Check
Walk-in RennP..%t
Your name: Mir) '
Address: 20 f6 if t
2C l!
City/State/%.i t, r A
Phone #: Is -7 -if 0666
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Fast ;1 (mandatory)
first Name Rimer Nom Bre (mandatory)
Middle Name Segzmdo iVbrraBre Qzcommended'I
IName 1pellido
U ru i rn
ikN1 I n
M 0 hst voaj
Date Of Birth Fecho ,K,,An ento (mandatory)
Gender Genuwo mandaaay)
Social SSecuri Number (re on,monaed)
D L�I 05/
[' Male El Female
j p a Z C
Waiver Fwma (If the request is on vourscIL please sign. Iftbe request is on someone else, write N/A)
�Signature
Results DC] USE ONLY
As of -`- 5 a name and date of birth check revealed:
MasterCard or Visa
(Last4 digits)
M
D
ANo record found
r);
❑ Record attached DO #
c a:
DCI initials
>
Q
Receipt
Number of requests i x $15.00 per last name = Total amount $ ) �--. p p
Method of payment: cash
Cardholder's name
DCI initials
Credit Card #
money order check #
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
Exp. Date
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MasterCard or Visa
(Last4 digits)
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