HomeMy WebLinkAbout15-234#sluma�
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO 2,"-3q
(Office Use Only)
APPLICATION FOR TAXICAB I 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
Middle
2. Address (REQUIRED) .1 LA�2ef F Ile _A",2_
3. Contact Information (REQUIRED) Email: Gw�ey ejYtd� �°lp�tcr..Cc:v� Cell Phone: (al
(All written communication sent via email)
4a. Chauffeurs License expiration date (REQUIRED) rbhl61201 &
b. Taxicab Business Name (REQUIRED) --C;vq (-).Cl 6 - . 6wq Ca
5 Prior experience in transportation of passengers: _ D -1faL& itt4i C Co �R�Ui (1 1 Cya
fll'ay4h aLt�.d� �U2cr� �—
n. Have you ever been arrested i charged with any misdemeanors and/or felonies in this State or elsewhere?
Where
When
What happened to the charge? (Circle one
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested /charged wit any traffic offenses in the last five years?
Type of offense Where When
What happened to the char e?(Circle one)'
11Rnvicted ismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ A
Type of offense
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name?
When
If yes, please provide theme(s)
A.-- Z, -
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATERTIF�,jD
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CK EIREI&W
You must apply for an individual Department of Criminal Investigation Report (form availa'lale'3PoA;.Tequestt .
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) "T j
r-
r�
0212095
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
1 hereby c rtify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�&2 QC $%� issued ono/. � expiring on /0/15/Zo /ti . 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 Appiicantl��?'-t',�5Date-o
STATE OF IOWA )
COUNTY OF JOHNSON )
=�
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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license 10 jr-) 11 12
�1zC)3
Signature Poli e Cliief or designee
L I�
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.
�v
Aignat&4—of City Clerk or designee
Date
ne:kiraxinanmanr,Faaai 99nlz ,,de MC 0312015
Office Use Only M
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Approved application
DCI report
State
c;i->''
certified driving record
Website update"
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4iiiWADOT
Si`<tA#ff R I a�l'rt}`,��i # CUS'TJ,%!CR 4R.'1'E�a vmki.towadot
Office at Driver Semcas
PO Six :42034 Dea Moir:'rea, A 6030i5-9204
Pt4na 5TE,-244-512418:i0-53-1-1121 I=ax: 515-231s-1837
vaa w lit adct:c0ov
Certified Abstract of Driving Record
Ary Date:
9/22/2015
DL/ID 4:
545AGO871(IA)
CDL Permit Class:
None
iorner 4:
5868786
Class:
❑
CDL Permit Issue
None
)9/2013
,.08/23/2013
S92
Speed
Date:
:IA
le:
Salih, Omer Elhaj
Audit 4:
5935755
CDL Permit
None
IOWA
Expiration Date:
cess:
105 1ST AVE
Issue Date:
04/20/2012
CDL Permit
None
•r
Endorsements:
�FORfVF
Offof iver rvices
Expiration Date:
IGj IS/2016
CDL Permit
None
Iowa DeparetmeSent Trransportation
t
Restrictions:
/State:
CORALVILLE, IA 522412502
Endorsements
3
ID Status:
None
Ing
PO BOX 452
Restrictions:
NONE
DL Status:
VAL
rens:
Restriction
None
CDL Status:
None
ing
IOWA CITY, IA 522440452
Supplement:
CDL Permit Status:
ELG
/State:
-of Sixth:
11/15/1961
CDL Cart Status:
None
M
CDL Med Status:
None
History Information
Fictions
tion Daze.. ...
_ Conviction Date....
ACD
ixpWnarion
County....
IUR_
)3/2013
03/25/2013
,592
......
Speed
'.Johnson
'IA
)9/2013
,.08/23/2013
S92
Speed
'.Iohnson
:IA
dents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
--.dent DateCase Number ;AUR
'0/2011 :648800 .._. .. IA.
se: Salih, Omer Elhai DL/ID: 54SAGO871
uant to Iowa Code §32110, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the
cdian 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
e, and that I have been authorized by the Director of the Iowa Department of Transportation to so certify,
fitness whereof, I have caused my signature and the sezl of the Department to be set upon this document, at Ankeny, Iowa taPisJ date:
'
-rn0
dyU/J,p)
X40¢••
9/22/2C15
IOWA
•r
�FORfVF
Offof iver rvices
Iowa DeparetmeSent Trransportation
t
ie: Sa,lh, Omer Elhaj DL/ID: 545AGO871
Sep22 2015 4,2DPM Div of Crlr6lna� fovrstigation No.6636 P. 6/13
Frp jf,;L ty o/ Iowa City Cierk 011lc=e 31Q sH BS447 OB/21/2015 llls- &zae P.002/002
STATE, O A0'YNA
Cl-ii7lilta,} History Record Cued?
R(eoff€q Form
n, Iowa UhIsiun l')f ('riminal fi wes0y;et pl,
Support Opernfious Lineal, 1" 1>[oor
2f5 E.'/"Street
Des Moines, )olwa S0319
(515)725-6066
(515) 72S-6680 Fax
1 AI11 requestintt An
tName
Record Cheek on:
First Name (n,sn
YXI Acc;wio Nlumbei: _- 'taa ;
(if applicable)
From:('iry of Iowa Com_
rily C 1e1-1i'xQfrce —
a1UL.Washin lnnfineci
fovea Cllp, 1A 522411
Phone: 319-356-5041
Far. 319-356-5497
C
Date of firth (mandamry9 Gender (manaalory) Social Security Number (recommeneea)
10/1)5 L �Nlaie ❑Nelualc ZZU �S — �5 z7
FT aiVeP Info oration Wi(IS out a signed trainer from the subject or the request, A complete criminal history record may not
be releasable, per Code of Iowa, Chapter 69)„2. For co. mnlele criminal history record information, as allowed by (&lv, alwaps
obtain a WAIYCI' 5iQnatllre rrom the subiect of the remlxcl
Waiver Release I Icleby give pen19s51on for Il)c above tcquesling 0MIiel1V eendvcl an luq'e cii,ninel history «c01d cLeck nilh the Division of Cri Minal
Ioyesli$alion (CI�:t), Ah)001)Mllil)ti me Ihel is ma' Clim{11a1 Iti610 da18
ry inlaincd �he 1)C]frray he released as allowed by len,
t{Wail -eY .iip7iliful'C:
1011yyy)r21 (- rnmicord Check Results
A; of -_ ��1 l$� a search ofthe Provided name and date of bidh
1PNo Iowa Crimumal liistlu'} Record mound with Dia
love Cri)Iminal hlis(ory ktecojd�a(tinh�ed. DL'1 if
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DCb77 (08125/10)
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