HomeMy WebLinkAbout15-225�r
CITY OF IOWA CITY
IDENTIFICATION NO.
(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)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(319) 356-SO40
13191 356-5497 FAX
First Middle Last
1. Name(REQUIRED) +tuvr>% Gist -a FlorwS��.
2. Address (REQUIRED) 5 o�,fi�9k�� Ip
3 Contact Information (REQUIRED) Email. w a 1�oywS QVAUL, l QoW Cell Phone: a0
(All written eommulcation sent via email)
4a. Chauffeur's License expiration date (REQUIRED) D 3/U /1 711-.
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
r�
Convicted Dismissed Deferred Suspended Plead Guilty rather
7. Have you been arrested /char ed with an traffic offenses in the last five years? n
Y 9 Y Y N C—, -
Type of offense Where B}en m ---
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty
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Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? -NO,
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
zf qA C 77 yi'd issued on o` 113 expiring on �,3/' O 6 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
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 'a DateLvL
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and�sw�or to before me by P'\) ra ;" `;.. %1gr)i c ' L� on this ] day of
WENDY
Public in
15911
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 ty`y %Coode).��j
Expiration date of Chauffeur's license �( 4 0
Signa e ce Chief or designee
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.
2gna�f'Ciy Clerk or designee
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Cep.152015 12.40PM Div of Criminal lnvestigation
No5800 1. 2
Oe/ll/2015 15:5 26'e x-.002/002
'S'S'ATE' Or IOWA
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"fo; IOWA I)ivialou ufCrimlnai lnves(igation
Support Orcra(ions liar -ca u, N' Glnsn'
215 h'. Vt street
Des hlolnm' Powe :x0319
(515) 725-6666'
(315) 725-6600"6 I+ax
Iowa
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(fapplieaple)
Brom: C_ItUy_lnwaCil:
City Oct k's offire
416 E. washin ton Ell cc(
Yhone: 31936-5047
m Male oFemaie
VIA die Xnme (reun,
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aoelat security Number- (rccom
[nfprmat'joll, Wilhoul n signed waiver front the subjec( of the request, a comple(c criminal history record may not
he releasable, per Code of Iowa, Chapter 692,2, For com Mete erimillat history record infol'tnation, as allowed by law, always
Obtain wawcr Sin turc from Ile s_u�iec( of the_requcsl.
IA,d ga of CI), icrth alid peennission toy the above regoesling o!(einl to conduct nn IoN'e oriminal history' record ehca niih the U M1
( ) M erinlin ry dale cmicen/ming me Thai is maintained by the DCI may be released as allotvrd by lhN. Division ei Qimhal
Waiver Si2rra&re. A–V—'OL_
aurva E f Itiliii�l k is�ar ' 2ecurd Chee C Restilts
As °I -- •--=1 �5_�5 __ a se.areh of (he Pruvided name and dale of bii7h revealed:
1\tu lowa Orinlhual MOO)-), Recoid found e'il)1
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l6wa Crbttiuol llistttr)kecurd attached, pCl ty' "' "
DC:1 ini(ials,_
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DCa-77 (O/25/10) __......_.
Received Time Sep 11, 2015 1:23pM No. 7764
(uca nsa m ly)
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Office of lirlvef Services
PO Box 5204 < Des l irte'9, to 50306-9204
Phone, 515-244-9124 1 8r 0-532-1121 I Fw, 51I 13L� -1637
w A.ieuado*.gov
Certified Abstract of Driving Record
Inquiry Date:
7/30/2015
DL/ID #:
Name:
Elgorashi, Amar Elmustafa
Class:
Address:
2504 BARTELT RD APT 1A
Audit #:
02/22/2013
CDL Status:
Issue Date:
City/State:
IOWA CITY, IA 522462714
Expiration Date:
3
CDL Med Status:
Endorsements:
Mailing Address:
2504 BARTELT RD APT 1A
Restrictions:
3/26/1984
Supplement:
Date of Birth:
Mailing City/State:
IOWA CITY, IA 522462714
Sex:
Name: Elgorashi, Amar Elmustafa DL/ID: 549AG7752
549AG7752 (IA)
Customer #:
5876365
D
ID Status:
None
6719060
DL Status:
VAL
02/22/2013
CDL Status:
None
03/26/2016
CDL Cert Status:
None
3
CDL Med Status:
None
Corrective Lenses
Restriction
None
3/26/1984
Supplement:
M
History Information
CLEAR DRIVING RECORD
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 1 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 tc be set upon this document, at Ankeny, Iowa this date,
:•'•----•--- fV-
7/30/2015
IOWA'4,
D. 0. T...:: -ii
f 9BIYE&
Office of Driver Services
Iowa Department of Transportation
Name: Elgorashi, Amar Elmustafa Dil 549AG7752