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Home My WebLink About16-026CITY 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. �-C,--:�L (Office Use Only) APPLICATION FOR TAXICAB / 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 r 2. Address (REQUIRED) A44 4 3. Contact Information (REQUIRED) Email: 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) r: 5. Prior experience in transportation of passengers: _ IN communication sent via Last 1 L Phone: 319 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? Type of offense Where lien What happened to the charge? (Circle one) Convicted Dismissed Deferred SuspendedPlead Guilty Othef-' 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? J 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 names) 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 ce tify that I have issued to me by the Iowa Depa tment of Transportation a valid Chauffeur's license number U issued on 522 ); expiring on c! p/ 19i�: . 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 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 T,� 9 r, of t City Code. (Needs to be sigma/R %� �t of a Notary Public) Signature of Applicant 1' / Date STATE OF IOWA ) COUNTY OF JOHNSON ) S scribed and sworn to before me by � a �l mA Ok an this _P =L, day of _ / 1 @ A h AIENDY S. MAYER a Notary Public in art for the State of I have reviewed this application, DCI report, and the State certified driving record of this applicant and have dgt§rmined that there is no information which would indicate that the issuance would be detrimental to the safety, health or weltdre of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Chauffeur's license 0 1 Ir, i L2017 - J, 1� U21litn� _ Signature of Police 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. Signa eofCitydr4designee ` Office Use Only Approved application DC]report State certified driving record Website update ClerkfrAXIDRIVEADGE PPL92014.m.nded.DCC 0312015 Dat ClerkfrAXIDRIVEADGE PPL92014.m.nded.DCC 0312015 C410WA DOT ifi J V,� t t .. �tt3! , SW RTL!' I j I pli ._6:1 B rl!FTO Civ `,[i1 Inquiry Date: 2/2/2016 Customer #: 2407754 Name: Ibrahim, Ibrahim Ali Address: 1027 DIANA ST Office of: Driver Serv[ces. PO Be, 9204. ! Des idaimes. to 50306;-9-G4 F7ione . 15-244-Q124 10ME32-1121 1 Fax 515- '39-118,37 www -me ado-gav Certified Abstract of Driving Record DL/ID #: 809ZZ1230 (IA) Class: D Audit #: 5996624 Issue Date: 05/22/2012 Expiration Date: 01/01/2017 City/State: IOWA CITY, IA 522404673 Endorsements: 3 Mailing 1027 DIANA ST Restrictions: Corrective Lenses Address: Restriction None Mailing IOWA CITY, IA 522404673 Supplement: City/State: Date of Birth: 1/1/1958 Sex: A History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: Office of Driver Services CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None Ccn-lU]on DaA* r,C:D nxplarretion Counts, j R _. )9/20/2015 .10/09/2015 .Improper Registration :Johnson IA Name: Ibrahim, Ibrahim Ali DL/ID: 809ZZ1230 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: "•:w{/�fIl 2/2/2016 r''••••"- Office of Driver Services w..�--- Iowa Department of Transportation Name: Ibrahim, Ibrahim Ali DL/ID: 809ZZ1230 Feb, 4: 2016 10:46AM Vv of Criminal Investigalien No6$45 P. 1/1 o2/D2/2016 16;6. ..380 STATE OF IOWA Criminal History Record) Cheek Request Form 'fns Iowa D10810, Of Criminal fn VC5tlg9tiO tl Support operatiods Bureeu, P Moor 215 E. 7'h Street Ile¢ MONO$, Iowa 50319 (.`.15) 725-6066 (515) 725.6000 .Pax I Alli re uestin anlo'-a Criminal History Record Check on: DCl Acootnrl Ntumber: goD3 — F (if Applicable) From; City oPlowa CiSv City Clorh's Office 410 E. Washin on Street Iowa City, IA 52240 Phone: _319-356.5041 Fax: 319-336-5997 $.a$t N211110 (mandatory)i1'St Name (mandalop) 1Y1iddle Name pecommenaen) �br'Th(� Date of/ Birth (n,andam,Y) Gender (mandaron•) social Securii Number (rreeconomendtd) �( I ( 1 5J 8 ErMale ElFetnale 9L / J 1'GU 4 Waiver kijorination: Ivithoul a signed waiver from the subject of the request, a complete erirninal history record may not be rtleasablq per Cade of Iowa, Chxpler 692.2. Pnr romnlele criminal history record information, as allowed by Ia,v, always Obtain a w'alyer sirrOature frarn tho nihicrr of eh> .o.. —, �frRlVCr X 8rE((S-e: 1 heavy give pernfis5ien Cor IIIc nbovc requcsline ofii r to wnducl an Io,+'a criminal bismryrecord check rcilh the Uivisial ofCriminal Inveniga(ion MCI). Any crilninal hislop&A cencerning nm dtet i3 Mainlaioe y,he, Indy be released As Ooe:cd bylaw. Waiver Signulure: 101va Criminal Histal-v Record Check Results IP('I ,Ise only) As of a search of the provided name and dale of birth revealed: _ r In No Iowa Criminal C-Iistory Record fommd will, DCI N -rt ❑ Iowa Criminal History Record otfached, DC1 # DCl imilialsCD _/v DCI -77 (08/25/10)-- Receivea Tlme Feb. 2• 2016 2:49FM 410 6703