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HomeMy WebLinkAbout15-232IDENTIFICATION NO. 15 — 3 d r 1 (Office Use Only) �.MWMW 1' APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER CITY OF 1 OWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) 410 East Washington Street Iowa city, Iowa 52240-1826 _Failure to complete the "required" information will result in denial of the application (3191 3S6-5040 (319) 3S6-5497 FAX First Middle Last r 1, Name (REQUIRED) A M C L P/I L �j i 5 C P- IZ 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email k A Nr L_ E /-G' s E6I?01'A«g,i$ell Phone:. (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) ! h / l r; J i S b. Taxicab Business Name (REQUIRED) 5, Prior experience in transportation of passengers: r�/T C L ,/_ 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /i C� Type of offense Where When What happened to the charge? (Circle one) 7. Convicted Dismissed Deferred Suspended Plead Guilty Have you been arrested /charged with any traffic offenses in the last five years? 6'her S' Type of offense WhereEn 71-;1 to l What happened to the charge? (Circle one) r 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? Type of offense 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) 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) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 2 ( r,' S !j issued on 2- r S - r S expiring on Is - 15 -- 15 1 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 docurnents 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 © STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by YQ -(,j IRA. 11__ on this ._a 7j day of IE ;Ln)s aR� WEN�Y S. MAYER o ommission Number 729428 Notary Public in d for fie State of I a o y 7-t ******************************k*#k*kk********£*************R*****x**khhk*************££***£**R*4**************k**k****************************** 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). license Expiration date of Chauffeur's 23 rJ ;® Signat re of PoliEd C60 or designee Date3 AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED � TO DRIVE A TAXICAB [W-1- VA 011 FODO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. r ' � I - Sign ure of City Clerk or desig ee Office Use Only Approved application DCI report State certified driving record Website update Date aerkr IDaivoaoceanPLszaiaamended.Doc 03/2015 40WDOT 1 } �`�� SMARTER I "IM, _1,R I "Ij)TOiiR DRVJ4 Xl �itliiV�i.Y43�+�Ci1tt Qv 0fcce of Driver Services PO Box 9204 1 Des Moi'.nees. IA 50XC-:7204 Fborke: 595-244-9124 1 Bi)0-532-1,121 1, Fax: 515-2ti9-1337 wwwSawaaetgov Inquiry Date: Customer Name: Address 9/15/2015 6409257 Certified Abstract of Driving Record DL/ID #: 942AL0754 (IA) CDL Permit Class: None Class: D Elgiseer, Kamel Mutasim Audit #: 9420754 Ali 902 BENTON DR APT 32 Issue Date: 09/15/2015 City/State: IOWA CITY, IA 522465219 Mailing 902 BENTON DR APT 32 Address: Mailing IOWA CITY, IA City/State: 522465219 Date of 12/14/1979 Birth: ELG Sex: M Expiration 12/14/2021 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CLEAR DRIVING RECORD CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Status: CDL Permit None Endorsements: ELG CDL Permit None Restrictions: Iowa Department of Transportation ID Status: None DL Status: VAL IOWA CDL Status: None COL Permit ELG ...... = Status: Iowa Department of Transportation CDL Cert Status: None N CDL Med Status: ,,,None � �) cn �^.. rT7 -0 CF: Name: Elgiseer, Kamel Mutasim Ali DL/ID: 942AL0754 w �.F Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of'Fransportation, 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: ""'•:��/,p'4r� 9/15/2015 IOWA ...... = Office of Driver Services Iowa Department of Transportation Name: Elgiseer, Kamel Mutasim Ali DL/ID: 942AL0754 Sep.17. 2015 2:46PM Div of Criminal Investigation No, 6163 P. 1%4 From:. -r [y or rows ..ny Clor rc vrtroa urn u5n eumi [)n H6/2016 ll:2n x264 e-.0 u2/D02 STATE ()F'10\VA Crtsnis�ad IiWonr Recuro Checi< R(%quesl For➢t1 '1'n: lama 1)IVkion pf (7r)minal In vesl(gafiun Su PP() 1'( Op eI'a flops Bureau, 7"Floor 215 L. 7" street Des 50319 5(1319 (515)729-6066 (515)725-6090 Fax am requestink an of 12—r`q-19�� WA Account Number:.....0 applicable) City C iorL'v Oflice 410 '- Wash illgion'treef Iowa clry, rp 52201 Phone: 319-356.$041 Fax: 319-356-5491 — ` "— I�rvla►e ❑Female N/\ V 1,9 5 ,1" P r_ 65Irr ��6 N Giver rnforntatioll: WlthOu( a signed Waiver from the subject of the request, a complete criminal history record oley not be releasable, per Code of lowal Chapter 692,2. For complete criminal history record information, as a1101ved by Inly, always ohfehla— �1Ya�Vetd�gpaturefrom tile SahiectnfAkin, renn el WaiVer Release; I kriby give penni5$an fol tha above rt uesfin o InvesGgeaan (UCIJ, Any criminal histo 4 g in tial to, An an larva criminal a )DNy /¢card abrck �rilb the ❑i�ision ar Giminel p' data aanctmin@ me Ihal is maimamed hr the UC(may be mleastd as allowed by Inn•, Waiver Signature; Iowa 0111111 121 Histor 1 record Check Results -- (fKl use wJ/q As of -1 -9 -t -2 -IS , _, a search of the. provided name and da(c of birth I'evealed:,.., No Iowa Criminal His(oIx lig liE 1 t � >y�r l'15'UC:1 f lovra Criminal How. 3, I (� yn�l }g�ul%�, Y pz i ;, cn _..1 fi )XI Inlllal > I,)(:1-77 (0812$/10) Received Time Seo. 16. 9015 11MAM No.5958 A