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HomeMy WebLinkAbout15-223IDENTIFICATION NO.�- ( 1 (Office Use Only) -4 APPLICATION FOR TAXICAB / MOTORIZED PEDICAS VEHICLE DRIVER CITY OF IOWA 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 (319) 356-5040 (3 19) 356-5497 FAX First1/ Middle Last 1 1, Name(REQUIRED) goyy-'1 n f1bmecl 2 Address (REQUIRED) .aoSer 14__(5�'A!Ey A 3. Contact Information (REQUIRED) Email: nrcf7elI Phcne_ �� (_3 727 (All written communication sentvia email) 4a. Chauffeur's License expiration date (REQUIRED) 10 / 15A -S; b. Taxicab Business Name (REQUIRED) _ -rca t! a L 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) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? HI d 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? Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please p �ide th�ani cra r'3 cn DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT?c6RTJFJED � DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE -"F REVIEvr— r'+'1 x,. � You must apply for an individual Department of Criminal Investigation Report (form avaliZi u; n rec�ub t). CD i.,�. (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) p 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certi¢�IAVEs j— o n the Iowa De a�dmen��t of Transportation a valid Chauffeur's license number `f j F L(�j issued on expiring on / 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 applic ion, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions Q 1 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) G Y i Signature of Applicant Date UIA/S STATE OF IOWA ) COUNTY OF JOHNSON ) �k Subscribed and sworn to before me by �5r �� 8 on this (O day of s�a��v�e�� aotb �'Notary Pub'ftc in and for the State o owa 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 Signature ofP ce ie 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. Signatr�te-of City Clerk or designee �L� Date V.l� tii3 Office Use Onlyt k7 -C _ Approved application :r DCI report I n State certified driving record` Website update > c " 0 -..r G9erP MIDRw6ADGE PPL52014.me deo.Doc 03/2015 SeP.1h. 201h 12:h2PMl Div of Criminal Investigation No. 0002 P, 1/1 Prorn:Cley o/ lows Qlxy 010ek omee 310 35G6n97 oa/10/3016 11:0b -2Ss STATE 04 i 0WA �rit iflal tfis(:ory Recnrd Chech s fZequesf Forin, T"ol Iar;x rti'Riun of CSinlinal lrvcsligs(iau upporl Operati[ms Him ait, 1"Ploor z 15 E. T^ 51 rue ( Des h4oinc_' lura 50319 (515) 725-6666 (51 s) 725-6080 Pax l F777 DC] lifap(hcenlc) .... From; Ci[v of lova Ci[y _ 9106' \Nasbinglai,)ueal •_–._-.__._'--.–_, _iuwa Cify,_lA 522411 Phune; 319-356.51191 Fax: 319.356•5497---.—."__.----- 1. ani requesting an )o wa Criminal History Record Check on: Lasf Name (inandemry) )\i ---- —�_ — Firs( atne (mandalu��_ —___ Nfiddie It'amc (recomniendnd> Date o(Bir t6 (manaso )91 0S� Gender (mandmory) Social S6curil'1luutber (recommenaef Umale ©Female Gi'aiver ri(jaPNtnfiOfl: Wi[hout a signed waiver Irani the subject or the request, a complete criminal history record may not be releasable, per Codc of losra, Chapter 692.2. For com1lete erimtnal his(ory record information, as ellolred by lane, always obtain a waiver si na(ure from the sub'ect of the request, ij'Oiver Aelease: l herb iv bl""llBUion (PCI). My crilni fall ldslory d ssion r h ;p rcDf 1�agncSling official la cond(JU m Iowa uiminol hiatorp record check with the Uivl:ion of Crimil�al fii rs ina1 1i l26M by the UCI may b, released as e)lowed by law. Iowa Criminal His�or record Check Results �— ^ -----_—. /� qs ft I' (T)CI axe clrlrl --- a search of the provided name and date of hirlh revealed: NO laud (,l'iniin[d History Record found with Do co •... —: III—...,. Iowa Criniioal l lislary Itecur(, attached, L)Cl I)(.1 illi 1£li5 o• r, Y Q : A r Wb Received Time Sep, 10. 2015 11:000 No. 7668 4'-JiUVVA00T wwwJowadotgov Office of Driver Services PO Box 9204, Des fomes, I,A 59306-9204 Fhnee_'F15-244-9124 1800-632-112t(Fay _5*5-230-1$.37 www lawif ooi..nJ'S Inquiry 9/15/2015 Date: 547 EMERALD ST APT Customer 6313623 Mailing IOWA CITY, IA Name: Ahmed, Bakri Osman Date of Fadlelmola Address: 547 EMERALD ST APT Sex: All City/State: IOWA CITY, IA Certified Abstract of Driving Record DL/ID #: 875AL7740 (IA) COL Permit Class: None Class: D Audit #: 9159430 Issue Date: 06/11/2015 Expiration 10/12/2020 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Ahmed, Bakri Osman Fadlelmola DL/ID: 875AL7740 CDL Permit Issue Date: CDL Permit Expiration Date: CDL Permit Endorsements: CDL Permit Restrictions: ID Status: DL Status: COL Status: CDL Permit Status: CDL Cert Status: CDL Med Status: None None None None None VAL None ELG None None Pursuant to Iowa Code §321.10, 1, 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: 522463010 Mailing 547 EMERALD ST APT Address: All Mailing IOWA CITY, IA City/State: 522463010 Date of 10/12/1957 Birth: 9/15/2015 Sex: M Certified Abstract of Driving Record DL/ID #: 875AL7740 (IA) COL Permit Class: None Class: D Audit #: 9159430 Issue Date: 06/11/2015 Expiration 10/12/2020 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Ahmed, Bakri Osman Fadlelmola DL/ID: 875AL7740 CDL Permit Issue Date: CDL Permit Expiration Date: CDL Permit Endorsements: CDL Permit Restrictions: ID Status: DL Status: COL Status: CDL Permit Status: CDL Cert Status: CDL Med Status: None None None None None VAL None ELG None None Pursuant to Iowa Code §321.10, 1, 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: Name: Ahmed, Bakri Osman Fadlelmola DL/ID: 87SAL7740 ry vqp 'aFiiiut °` e N ............ /'/a V1 9/15/2015 IOWA 8®'' C3 59 9f 1****1* $�=� Office Driver <<<r' vi a of Services Iowa Department of Transportation4�: % C7 a Name: Ahmed, Bakri Osman Fadlelmola DL/ID: 87SAL7740