HomeMy WebLinkAbout16-013IDENTIFICATION NO.F-r
(Office Use Only)
° ZOXTI
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
4 i East Washinglon Street
_Iowa._ it , 1oir-a 52240 1 826 Failwto compl
e ete the `repaired" inform-rtron wilt resuti in denial of the application
6191356-$040
(319)356-5497 FAX
First Middle Last
1. Name (RFr)UIRLD) _ j, g)4n..g n - in0!j m -� ))
2. Address(RFQUIREDi 2144 4 v EIi _G k,/ IT t 919LkL
3. Contact Information (REQUIREL)) Finail: ;
(Allwntte�
communication
sent via email)
4a. Chauffeur's License expiration date
b. Taxicab Business Name (REQUIREI
5. Prior experience in transportation of
6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere? 00
T e of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested I charged with any traffic offenses in the last five years?
Tope 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? / V 0
Type of offense
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please
. 1
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAI
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE
You must apply for an individual Department of Criminal Investigation Report (form
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
When
"1 Q
t
F -19D
RIE EW
upon request),
+t�
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license m:mber
l�i�� tj `f(1 issued on .Ipfl�/zW expiring on O o O. I understand that if I
falsely answer any questions In this application, that this app icat7 ion may be denied. I 7grWthat 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 ofApplicant�ir -.= Date 1 l r
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STATE OF IOWA )
COUNTY OF JOHNSON }
Subscribed and sworn to before me by
in
11�`
en this day of
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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).
Exle"ati n date of Cha feul license I C,
az 7
Signature o Police Chief o esignee 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.
gnatUre of City Clerk or designee
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Office Use Only
Approved application
DCI report
Slate certified driving record
Website update
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- .,.�---_�-- - --
Office of Pliver Services
PO Boz 0204 : Das tAGMes, M 5030"-204
PRone: 515.-244-9124 f 8046.32-1121 I Fay :.%15-.239-1837
www. iowadat..gov
Inquiry Date:
8/11/2015
Name:
Abdelrazig, Abdel Rahman
CDL Cert Status:
Mohamed
Address:
2442 WHISPERING
Restriction
MEADOW DR
City/State:
IOWA CITY, IA 522406805
Mailing Address:
2442 WHISPERING
;S92
MEADOW DR
Mailing City/State: IOWA CIT', IA 522406805
Convictions
Certified Abstract of Driving Record
DL/ID #: 214CC9840 (IA)
Class: D
Audit #: 8537734
Issue Date: 10/16/2014
Expiration Date: 01/01/2020
Endorsements: 3
Restrictions: NONE
Date of Birth; 1/1/1956
Sex: M
History Information
Customer #: 4313828
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
IA
Citation Date
Conviction Date
ACD
c'wplanatlon
Count-
Stir,
12/23/2011
.01/03/2012
592
Speed
3ohnson
IA
11/12/2014
11/25/2014
;S92
Speed (10 mph & under in 35-55 mph zone)
Washington
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
i:ccident Date
Case Number
JUR
10/14/2011 _.._. _. _
_... 653163
_.. .....
IA
39/08/2012
_.. .._
.702582
.. .. � -
34%20/2015
.855323 -.... _ _
.. _,... .._..
iA
Name: Abdelrazig, Abdel Rahman Mohamed DL/1D: 214CC9840
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 oft he 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:
.......;ipI.,f
8/11/2015
Pill
Office of Driver Services
`harm .
Iowa Department of Transportation
Name: Abdelrazig, Abdel Rahman Mohamed DL/ID: 214CC9840
Aug. D. 2015 12:35PNr Div cf Criminal InveFtig;tion No. 2626 P. 1/1
Fr -...._..r •-. ,_..t Ctw_ ._... -.- `....,..._o, 00/07/2016 1J:— 3119, —21002
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Cl€ iiinal M.0ory Rew.r i �:hcck
~L.- ltec�tbest )i arm qw
"T'u: lovra Division aT Criminal Invastlgation
Support Upera[hens Durea n, i" l�lnuf
115 G, 71q 5lracl
lies Moines, sown 50319
(515)725.6066
(515)725-6486 Fay.
T'S< "
First
DC;1 Accoupl Nnrdher.
Front: _ CI of
C113, Cicrl: s Uftre
414 LyL.s1Lnklon
fama Citi -!L %7 40 "-
!'bone: 319-356-5641
Fas: 3[9-356-5491
'
Hate of Birth (wmww y) -- If (Gender (=,damn,, Social SnruH hr Nr.r
C I dj ra (>I pl%124 ❑Female I o 1 9 [ L[C
Waiver jrrforf1wrion Without a signed waiver from Ibe subject of the nogZ; a comple{c cr)minal hislory reeord may not
be releasable, pet' Coda of lows, Chapter 692.2, For comnle[e criminal bi6tory record information, as allalwed by laly, always
ablaln a N'91VCr SiPbaLn•r rrnm lhn cuhi.nr nfeho sea
Waiper Relzase; I hcmby give pennissiao for the above requesting official Ia wnEacl an Iowa criminal history rwnd check nvidtThe Division or Criminal
1AMUe6tion XI). Any criininal hislop' dare w111114 me ofal is malmaisied bywe DCl maybe released as albwed by lasv.
tNtiver Signafure:
Iowa Crigninal Mister t Upegn-ti Cheek Results DCt aer only)
Asof RI[QL '� j _— a search of the provided [tame and dale of bink ceveeler{i;_
�l
No lova Criminal Histary Record fowid with DC1
I �; i -• i r5
EJ )oN'6 Criminal I•listol)' Record att;aohed, DCl 9 _ u
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171:1 initials
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Received Timc Aug. 7. 2015 2:25FPi No,4908