HomeMy WebLinkAbout15-235�
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. I Is _ a 3S
(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
1. Name (REQUIRED)
First j U I -T 4 d Middle T) iC',tl h Last
f
2. Address (REQUIRED) 26tT Q gakd-5 Ra, Ael, 2 b M wcj U.
3. Contact Information (REQUIRED) Email SU 1 j -y)1'' jI 196 Z �h'A C-C"rell Phone
(All written communication ent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: lo, 6 r G F i
AI �W `-Pry v is
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Tyoe 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? /v 0
Type of offense Where
When
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C/)
9. �d
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pro$ hle thetNme(s;"
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE &ERTIFIIe �1
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVJEW
-r
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 caret at I have issued to me by the Iowa Department oTransportation a valid Chauffeur's license number
slued on -27 -13 expiring on 4Q.L 2_ / I understand that if I
falsely answer any questions in this application, that this ap lication maybe 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 � "4 / Date - 2 4 - / _�—
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by S jj) 4-n *e , on this
- 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).
Expiration date of Chauffeur's license c ( /o( /Zo2-L_
Signature401iR119—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.
Signatufe of City Clerk or designee
/'z 5 b' -
Date /
Office Use Only
Approved application
ten
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DCI report
-
State certified driving record�j
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STATE Gf f(DWA
Crimi"f Kisfo>rY Record Check
Reegeaes>F Fog -m' '
Tu; lova 1Dlvfsfoa oPCriminal Inaestigation
i-upport Uperatlons Bureau, 1" Plnor
215 C, 7"' Street
Des Moines, laeva 50319
(515) 725-6066
(515)725-608o Fax
an lowa W mimal History Record Cheek on:
Date oFSirth (a,anealnry)
Gender fmandemrvl
17CI Account Number: `7 — F
(ifapplicable)
Prom S i of lows Ci¢y
City Clurlc's Uffice -'-----
910 C. OVashSaglon Sfrect
Iowa CI}y, 1A §2240
Phone; 319-355-5041__
Fas. 314-356 549y
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0/mAle. Cll+emale/%S 7'�
il'ar ver 1flf0rrnafi07t, Without a signed vvalver frmn the suhiect of the request' a complete criminal history record ma not
be releasable, per Cade of Iowa, Chapter 692 ,2. For co_ nplef2 criminal histot'y record infarmation, as allowed by law, almays
obtain a waiver si nature from (he subject of the reouest.
Waiver Release; I hercb), eiyc C Il11SSion far [lit BhoYc regVCSline Official to conduct m lows criwillal histcfl record check rpilh the Ulvigo, of CrigUlld]
Invevigalion (DCq_ Any Bfiminal lmlop• dala coaccrning nit Ibet h o kIllincd by Ilia DCI may bcreleased ac allowed by 1my,
W(tiverSigr:rdrtre:_ 5 v �� r �% , `--,., h. ,I
Iowa Criminal Histor Record ChecP� ResrlIts —�
As of, 9 �� a search of the Provided Hanle and date of hiilh resealed:
Int 1\10 lova Crilxlinal Hisl(Dry Record found with DC1
❑ lowa Criminal History Record attach
ed
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DCI
DC1 initials / "�
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Office of Driver Services
FO Boe5204 Des Moines- IA 5030,-9204
Pho-v: 516-244-9124 1 S00-532-1 `21 1 Fa.. 515-239-1?137
A�w iowaoo-.00i•
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
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 52 24 62 74 3
Endorsements:
2
ID Status:
None
Mailing
2658 ROBERTS RD APT 21)
Restrictions:
NONE
DL 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: 832AK7271
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:
IOWA':.'
9/22/2015
Pit �
Office of Driver Services
m
Iowa Department of Transportation
Name: All, Sultan Dirar DL/ID: 832AK7271
9/22/2015