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HomeMy WebLinkAbout16-022CITY OF IOWA CITY IDENTIFICATION NO. )G -02-2- (Office U2-2(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) 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 (319) 356-5497 FAX First1 MidJ� le Last / 1. Name(REQUIRED) Aho—/-� P-6<SCiL7 2. Address (REQUIRED) �C PGF f� L�tf to} Ii , -I- 12Zv-tl 3. Contact Information (REQUIRED) EmaiC//catc� n� In „�- r„w Cell Phone3,) (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) c1/ ClJ %z�i b. Taxicab Business Name (REQUIRED)_ 71 12( Yt�L7/ i7L/ 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? /L/1 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? A-10 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 WhL�fi G3 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the na 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�eby ce ify that I hT issued to me by the Iowa Department of Transportation a valid Chauffeur's license number issued on/) expiring on CL I understand that if I false(}- answer any questions in this application, that this applic tion may be denied. I gre that in snaking 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 0 03 / STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by AIA w -e A%0 4=<aAcLP ) on this day of 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 25Y2 /211 )Z� Signature of e rhief or designee u3/tel -� 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. Signature of City Clerk or designee Approved application DCI report State certified driving record Website update Date Office Use Only ♦ M Clerk(rAXIDRNBADGFAPPLUDI 4amended.DOG 03/2015 F heb. 2016„ 9:01AM O1eY3 3e lv -Div of Criminal Investigation o�l�© o g No,6551P.1/2 O03 /y ,nn yr�2STATE , OF IOWA A crilininal History Record Check To: Iowa Division of CPlmilia I III vestigatioll Support Operations Rureae, V Ftoci 215 C. 7'h Street. Deg Wines, lows 50319 (515)125.6066 (515) 725-6080 Fax aur scy ucgslnR atl J.owa ("1'11111114 Last Name (ma„datary) Date Of Birth (mandatory) _ c3�' ����/ I 40 9 DCI Account )dumber: 7 Z — F -- (ilayplicable) ' From: _ C:ity oflawa City City Clerk's Office �'_-- 410 E. Washington -Street Iowa City, IA 52240 Phone: 319-356-5041 F= 319-356-5497 "— Check A Vild f -Hale E Feni _fc�i �'l 3 T6,0 - 9e/- I ` Lyo waiver Inforntatioft: Without a signed waiver from the subject of the request, a complete erhninal history record may not be releasable, per Code of Iowa, Chapter 692.2. For co_ mnlete criminal history record information, as allowed by late, always obtala a WRIVOr slgneful'e from the Subiect of Flip remmer Waiver Release: 1 hereby give permission for rbc above requeslingoffrciol m conduct on Iowa criminal history record check With the Division of Criminal Invesaghh't, (PCI). Any criminal hitterydala coll"%q1 l( 1at is maintained by the DU rney be released as allowed by lbw. lFttfvef• Signarure: Iowa Criminal History Record Check Results (DCI use roily) As of �-� - a search of the provided name and date of biJ14 revealed; r y c_ �` No Iowa CS-inlinal History Record found with and ❑ Iowa Criminal llistrny Record ariached, DCI # Y -- ry ,J DCT fiiWal8-1,LJ I)CI-77 (08/25/10)� m~— Received Time Jan,29. 2016 12;01PM No,6322 Ziu"ADOT �.-►y IMPAV ItJW8G0t.gOV SMiAVFEF I Sff,F1,1 fIPSIOV" r uRke1E'i�..��� Office of Driver Services PO Bar 9204 Des Moines. IA 50306-9204 PtIone_115-244-91241800-532-1121 1 Far 915-239-1837 ww^ar.io�.aco?. gov Certified Abstract of Driving Record Inquiry Date: 1/29/2016 DL/ID #: 732A16748 (IA) CDL Permit Class: None Customer 9: 6138609 Class: D CDL Permit Issue None Date: Name: Ismail, Ahmed Hassan Audit #: 8729082 CDL Permit None Expiration Date: Address: 2105 PLAENVIEW DR Issue Date: 12/31/2014 CDL Permit None Endorsements: Expiration Date: 05/02/2016 COL Permit None Restrictions: City/State: IOWA CITY, IA 52246 Endorsements: 3 ID Status: None Mailing 2105 PLAENVIEW DR Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 52246 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 8/2/1970 CDL Cert Status: None Sex: M CDL Med Status: None History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number ]UR 02/16/2015 846134 IA Name: Ismail, Ahmed Hassan DL/ID: 732AI6748 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: 1/29/2016��,, f,,/ IOWA D.O.T. -`&ueav-v y c/�.. — rf•g'�°e Office of Driver Services Iowa Department of Transportation Name: Ismail, Ahmed Hassan DL/ID: 732AJ6748