HomeMy WebLinkAbout16-045CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO.
1� - c)
(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
3. Contact Information (REQUIRED) Email 301t -6k n t-Ck V Cts b Cell Phone 3I &5 Lf%G J)Z
(All written municationssent via email)
4a. Chauffeur's License expiration date (REQUIRED) "-1 ! ZZ /
It. Taxicab Business Name (REQUIRED) �C W fnyx'�
5. Prior experience in transportation of passengers:
t-3
151
of
Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
FIamss,-AV413Rc W-i-
Tvpeofoffense Iylsg Where When
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What happened to the charge? (Circle
2 Convicted \ Dismissed _ Deferred
we
Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Ll
Type of offense
Where
When
onvicte Dismissed Deferred Suspended Plead Guilty Other AZO
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? dV
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 ce ify that yI have issued to me by the Iowa Dep rtme t of Transportatiory a valid Ch ffeur's license number
Z_j9 Q "I Z � � issued on 3 Z2r 1_ expiring on 1� ZZU, 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date I
ti
STATE OF IOWA )
COUNTY OF JOHNSON )
SPsc�bed and sworn, to before me by �� C) N cin N-�9...c� on this
,r ._ r n/1 _
'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 l L-2,: -1 2 �,_)>' 9
Signature of P711lef or 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.
�24/A
Signatur&of City Clerk or design
Office Use Only
Approved application
DCI report
State certified driving record
Website update
1,2
Date
Clerkl MDRNBADGEAPPL92014amended.DDC 0312015
FJan,26. 2016,, 3�50PNi01e-Div of Criminal Investigation No, 6151 F. 1/3
01/ms/2016 12 0, 0392 P,002/002
CaJ
G�
'TATE OF IOWA
Criminal History Record Chnk
Request form
To: Ior;a Uiv cion of C:rirninnl tuveatigatlrrn
SUPOott £Sttetations Bureau, I"Floor
215 C. 7i' Street
D" KOhies, lows 50319
(515) 725-606.-
(515) 725-60go
25-6066(515)725-6050 F&x
1
Del AccountAlambcr
(ifoPVpcable)
F'rnr: _ Ci. ty op loava City
City Clorlds 0['Ficr,
A701;. W__�S11LIp_lon Stregt
101VA City, IA 52240
Pho e: 319,356-5041
Fax: 319-3565499��
It
LN
No Iowa Ciiraival History Record found with DCI
IoHa C'rintinal History Record attached, DCI
DQ -77 (08/25110)
Received Time Jan, 25. 2016 10:52AM No. 5983
Pi 00T
• . ►' c;+,� ATER ! `f;`ai}! ICI+,Eli "r t' r=lil Pd ay ICt Ir C C .0 t 11
inquiry
Date:
Customer
Name:
Address
2/4/2016
5409180
Ahmed, Ali Omer Ali
Office of Driver Services
PO Box 9204 e. Des Memos, IA 503C6-9204
Phu;e 515-244-9124 1 800 522-1121 I Fat 535-239-4£:37
www iovtadot.aoV
Certified Abstract of Driving Record
DL/ID #: 248AD4337 (IA) CDL Permit Class: None
Class: D
Audit #: 8961645
2654 ROBERTS RD APT Issue Date: 03/27/2015
1A
City/State: IOWA CITY, IA
522462741
Mailing PO BOX 2532
Address:
Mailing IOWA CITY, IA
City/State: 522442532
Date of 9/22/1968
Birth:
Sex: M
Convictions
Expiration 09/22/2018
Date:
Endorsements: 3
Restrictions: NONE
Restriction None
Supplement:
History Information
COL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
DL Status: VAL z
CDL Status: None
CDL Permit ELG_
Status:
CDL Cert Status: None
CDL Med Status: None
Atation Da>e Conviction Date ACD Explanation County .ku€Z
19/01/2012 11/08/2012 -M14 Fail to Obey Traffic Sign/Signal Johnson IIA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
accident Date Case riumher JUR
12/12/2015 895326 _.. .IA
Name: Ahmed, Ali Omer Ali DL/ID: 248AD4337
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: