HomeMy WebLinkAbout16-029CITY OF IOWA CITY
410 Last Washington Street
Iowa City, Iowa 52240-1825
(319) 356-5040
(3191 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. (L— 0 �k
(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
3. Contact Information (REQUIRED) Email:
(All written
4a. Chauffeur's License expiration date (REQUIRE
b. Taxicab Business Name (REQUIRED)
5.
sent via email)
a211-If�>-a16
Phone: `K -'333-2(4,
Prior experience in transportation of passengers:
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) r i
Convicted Dismissed Deferred Suspended Plead Guilty .ti -Other ='
7. Have you been arrested / charged with any traffic offenses in the last five years? �f j
Type of offense Where .When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
S. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? n26
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 Transpo Cation v lid Chauffeur's license number
67 22 ]� 70 sued on 2 $ISexpiring on v5 t %s 7P. 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant _ Date c; 17 �D
STATE OF IOWA )
COUNTYOFJOHNSON )
and sworn to before me by�, ), I _�F,� r��Acn this �`� day of
and
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 Cha feur's license / I �I %� 2 C)
6:1�/Z16
Signature oe Police Chief o signee b to
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.
Signatur-of City Clerk or designee
Office Use Only
� mate
Approved application
DCI report
State certified driving record T
Website update c
v
Cler AXIDRIVBADGEAPPL92014amended DOC 03/20155
F,oFeb.11- 2U16,,,10:09AM_Io,kDiv of Criminal Investigafioo0--/08/2016J2No.711;3B6N h2/Qa2
CYimiSTATE OF IOWA
nal History Record Check
Request Form
TO Iowa Division of Criminal Invcatdgafiomt
Support Operatimes Bureau, f'r moor
215 C. 7'i' Street
Des Moines, Iowa 60319
(315) 725.6056
(514) 725.6000 Fax
an
1 6 rq Y 1 I h`)
Check on:
DCIAccOuntNumber: ! 00Q -l✓
(ireppliaflble)
From: City of Ca1va C'Ity�` _
City Clerk's OfGCe l-`---
41 U _uV-- hen ton $tree[
Iowa Cltyy_fA 12240
plionc: 3I9-356.5041
Fax: 319-356.5497 --
d M qua b
OS t?( 6 QMale ❑Female 16 !s ` 9 61_ tet" B66
%Vn9ver InfDrnmfiDn: Without a signed waiver ft'om the sub]ecf of the re0ucst, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 691.Z. For comniete criminal history record information, as allowed by law, always
011141111 a waiver signature from the subiect of the rnna�er
W(fiver Aeiease: 1 hereby give permission for the above requestiq official to conduce Ml,,, criminal hisioh record meek with the Division of Criminal
Inveslisariml (Del) Wry «Iminal history data concemi� me that is maimeined by the Del may be released as allowed bylaw,
Wil Iver 91,enajuj e:
Iowa Criminal History ]Record Check Results
/ (L)C) uSDpnly)
As of �/ //6, a search of the p,ovided name and date of birth revealed:
No Iowa Cfiminal History Record found with DCI F'-
r.. t..r
Iowa Criminal History Record attached, DCI
OCI-77 (08/25/10) — �_ µ----- ---
Received Time Feb. 8. 2016 12:13PM No,6867
4,Vy
i\
Iowa department of Transportation
CAW Office or Dni Services {Toll Ffee18D(Ffi321121
PO DDx 9294, 685 Mani IA. 503W9204 515-244-9124
FAX 515 239 1837
Certified Abstract of Driving Record
Inquiry Date:
2/16/2016
DL/ID #:
422AF7170(IA)
Customer #:
5609235
Name:
Ibrahim, Saifaldin
Class:
D
ID Status:
None
Omarab
Address:
2401 BARTELT RD
Audit #:
8788773
DL Status:
VAL
APT 2C
Issue Date:
01/23/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
05/13/2020
CDL Cert Status:
None
522462701
Endorsements:
2
CDL Med Status:
None
Mailing Address:
2401 BARTELT RD
Restrictions:
NONE
Restriction
None
APT 2C
Supplement:
Date of Birth:
5/13/1960
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522462701
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number
]UR
06/12/2013
744204
IA
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Tran`portation, do
J
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a tciie and accurate copy of
an official record currently in the custody of said Office, and that I have been authorized by the Director' --,he Iotr jDepartment
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, aE_Ankei-V, Iowa
this date: - - -
E:'1
C.]
2/15/2016
cl�gIYHFT Office of Driver Services
Iowa Department of Transporation
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170