HomeMy WebLinkAbout16-025IDENTIFICATION NO. I�, — c)-
1 l 1 (Office Use Only)
® IIS It
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)
410 East Washington Street
Iowa city, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
Fi t�' Iddl r,I 'I Last
1. Name (REQUIRED) / t G L �A ) 1/Vt.C- \�A
2. Address (REQUIRED) 6y VIn�U 1� �Q �l bWA 5-2 2. h
3. Contact Information (REQUIRED) Email: PhoneYl 330 _ `{ eio
(All written communication. sent via email)
4a. Chauffeur's License expiration date (REQUIRED) /6 12-4 / 2 0 2- a
b. Taxicab Business Name (REQUIRED) _ CL
5. Prior experience in transportation of passengers: V) ff 1,LCL
& \ S ih,
cc -)y
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
N 7. Have you been arrested 1 charged with any traffic offenses in the last five years? %� U
Type of offense
What happened to the charge? (Circle one)
Where
When
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
-n
N !i
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the*ame(5,),.,,
�CD
,.,
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE,CERTIFIr-,D
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 Depa ment of Transportation a valid Chauffeur's license number
C
L" C4 �c!�) � �, j k issued on %U expiring on i012G 12nd I understand that if I
falsely answer any questions in this application, that this application ay 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 App1ican0ZdL_S1A.rn_aM0` Datea le/
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by l -c21 IA DS Ki- on this 9R,_- 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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license �_/26c Z07,0
---
Signature o Pdice 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.
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
41q /,I e-
, Date
cierWrnxmRivenoce PPLszmgamended.Doc 03/2015
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cierWrnxmRivenoce PPLszmgamended.Doc 03/2015
eti. S, 2Ul 0 2:12FM Illy 0 Criminal finvestlgation No, p 1120
01/26/201C ,6:6m 0 1 r_J02/002
N 4pfit
OF
IOWA A
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e Iowa
8History
I �
rrc�✓y'
vRequest
li
To: Coma Division of Ctimioal Investigation
Support Operations Ciureau, 0 Floor
215 E. ?"Street
Des Moines, Iowa 50319
(515)725.6066
(515)125-6090 Fax
re uestin an Iowa Critnival Histol Record Check on:
t Na Ute (mandatory) Virst Name 0naodet
DC1 AccountNuirber: '
(itappliwblc)
From: CilyaflawaCity
City Clerk's Offio
410 E. Washinatm, Street
loNva City, IA 52240
Phone; 319-356-5041
Fax: 319 -156 -
requesting
19 -356 -
Middle
��e 141,11,
Social Securi' NUmbeY rccommentled)
❑Female ( IF —S;6 -- 16,� 4
Wa'VBP 1100PrzM601z: WilhOuI A signed waiver from the subject of the request, it complete criminal history rccord may not
be releasable, per Cade of Iowa, Chapter 692.2. For complete criminal history record information, as alCmved bylaw, always
oD[aln a waiversienettn•e frnrn me e„n;o,.r „r et.,..e,..,...,
Waiver Release: I hereby give pcm,ission Por du above regoesling dPrciel to corduc( an Iowa criminal hISIDry rccord check 11itb the Division arCriminal
lnyestigatlon (DCI). Any triminnl WWI), data concerning ,c that u maintahmd by the DCI may be released os elloIved by lain.
Waivel,sienanrr�i\� t��1nA �—�.t i.l n
Iowa Criminal History record Check Results
(D(:I Ilse only)
As oP/ % a search of the provided na1.,e and date of birch revealed:�
I.
No Iowa Crintival History Record found with DCI
r.
® Iowa Criminal History Record attached, DCI #_
v
DCI initials v ''
T r
DCI -77 (08/25/10)
Received Time Jan.26, 2016 3:41PM No -6109
CIowa Department of Transportation
Office eft Unver ! r r, ices fill C me) 8W 532 1121
PC Boo: 3204 Ues Maws, IIA 503D6 9234 515.244 9124
AVAX: 915 234 1B3r
Certified Abstract of Driving Record
Inquiry Date:
2/8/2016
DL/ID #:
249AD2618(IA)
Customer #:
5410029
Name:
Osman, Adil
Class:
D
ID Status:
None
Mohyeldin
Address:
647 EMERALD ST
Audit #:
9483247
DL Status:
VAL
APT C9
Issue Date:
10/09/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
10/26/2020
CDL Cert Status:
None
522463027
Endorsements:
3
COL Med Status:
None
Mailing Address:
647 EMERALD ST
Restrictions:
NONE
Restriction
None
APT C9
Supplement:
Date of Birth:
10/26/1969
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522463027
History
Information
Convictions
Citation Date
Conviction Date
ACD
Ex lanation
Count
]UR
10/29/2011
01/30,/2012
M14
Fail to Obey Traffic
Si n/Si nal
Johnson
IA
Name: Osman, Adil Mohyeldin DL/ID: 249AD2618
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:
f�tA1f N4 2,/8/2016
D. {). T
�- Office of Driver Services
Iowa Department of Transporation