Loading...
HomeMy WebLinkAbout15-269CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX I. Name (REQUIRED) IDENTIFICATION NO. is-- (D I (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 A4-1 L -1—c-, Jti J V V 2. Address (REQUIRED) All 4c,t het St• leu �U 11R 1.4 C2yKl 3 Contact Information (REQUIRED) EmaiP, c'e� Cell Phone: 130j`5(p— (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED)©(P � ' b. Taxicab Business Name (REQUIRED) _CA Cl 5. Prior experience in transportation of passengers: 06 a- Tj 1 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense What happened to the charge? (Circle one) Where When 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 What happened to the charge? (Circle one) Convicted Dismissed Deferred When 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 Depart ent of Transportation a valiV Chauffeur's license number (v � C( L issued on 0 2- lexpiring on o (o, . I understand that if I falsely answeV a y questions in this application, that this applic tion ay be denied. I agree t at 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 ) Date STATE OF IOWA ) COUNTY OF JOHNSON ) �i e � arvv; � on this �J(:)_ `-'da of 5 scrib d nd sworn to before me by y or u «W€ c TUTRe er2218Not ublic in and for the State of Iowa �mb19 ***************k*k*#**k********...... k........... k**k*k***kk*k********kk*************************************k**************************kk**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). Expiration date of Chauffeur's license / Wi(61-z o l Signature of PIDli Chief 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. Signat of City Clerk or designee ` Office Use Only Approved application DCI report State certified driving record Website update ate C1e6,7AXIDRIVEAD GEAPPL92014amwd d.DOC 03/2015 Iowa Department of Transportation o � c hr c' 1t Clr:vpr'_,crvlres Ili'YII111#;Ji W1 11:,1 F'0 Bo Dirt, Uc� M��l"5c5.:A tiC3[,¢ �!'':H1 1,1� 244 !i,.�a "r 1, A'X S1`.' 231? 193r Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Certified Abstract of Driving Record ]UR Inquiry Date: 10/30/2015 DL/ID #: 713YY6890 (IA) Customer #: 2068875 Name: Hagelamin, Tawfig Class: D ID Status: None Ali Elsiddig Address: 811 HUGHES ST Audit #: 6119105 DL Status: VAL Issue Date: 07/12/2012 CDL Status: None City/State: CORALVILLE, IA Expiration Date: 07/16/2017 CDL Cert Status: None 522412143 Endorsements: 3 CDL Med Status: None Mailing Address: 811 HUGHES ST Restrictions: NONE Restriction None Supplement: Date of Birth: 7/16/1980 Mailing CORALVILLE, IA sex: M City/State: 522412143 History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number ]UR 01/21/2015 841521 IA Name: Hagelamin, Tawfig Ali Elsiddig DL/ID: 713YY669C 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: ��LL�f lIq' 10/30/2015 _o�.�.jly��''i1�Ilit 411, 4 .. 88�1J46 Office of Driver Services �}lh���rs.�..c.�'': Iowa Department of Transpora[ion Name: Hagelamin, Tawfig Ali Elsiddig DL/ID: 713YY6890 Oct,27. 2015 10:55AM Div of C r i m l n a I Investigation No. 9522 P, 707 F'r _.. --- ------, 10121/Rol6 18:fic -God r.uu2/002 F X111 OF 1_UFjr STATE 1 OF IOWA �■ r o� �rr,^ ,ry, IOWA r History Record Check - Request Form �`T To: Iowa Division ofC'riminol Ynvestlgation Support Operations Bureau, I" Floor 215 E. 71h street Des Moines, Iowa 50319 (515)725-6066 (515)725-6060 Fax I am reouestine an anula Criminal Wiefn, P2 ,c A Chnelr DCl Account Numbef,'l� w (it applicabIa) From: City of lona city City Cleric's Offtee 410 E. Washington Street Lova Cft lA 52240 Phone: 319356-5041 }aX: 319-356-5497 Last Name (mw,datary) —_ First Name (maadalory) Middle Name (recommended) N 11c; Date ofBirth(n,andatoly) txender (mamendaeory) Soccial7Securih' Npumber (lreeo/u�,mendea) r" I I/ a U �u ivialC �Fehlale 1Y.7 J tO 0 S G D%� 6Naiver• Informarionr Without a signed waiver nom the subject of the request, a complete criminal history record may not be releasable, per Code of lova, Chapter 692.2. For complete criminal history record information, as allowed by low, always obtain a vralver si nature from the Subject of the request. 1'I/ INCA- Ae'.ieaSe! I hereby give p rilission for the above requesting omcisl Io conduce an lows criminal history record check With rhe Division oPCriminal Invosligafioa (DCI), Any uunlnal history Bala concerning ma that is mainlaincd by the DCI maybe released as alloyed bylaw. Waiver Signahrre: (Dul tub only) As of a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI ® Iowa Criminal 13i8tory Record attached, DCI ii-2 DCI initials DCI.77 (08/25/10) Received Time Oc1.21, 2015 4:20PM No,9095