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HomeMy WebLinkAbout16-057!rQ.dmi� It CITY OF IOWA CITY 410 East Washington Street Iowa city, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 PAX IDENTIFICATION NO. l e U$ (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) Failure to complete the "required" information will result in denial of the application FiPt 1. Name (REQUIRED) ;�j" 2. Address (REQUIRED) / ' 0 Last S hero 3. Contact Information (REQUIRED) Emailnk� jr\rnq _(cLI' Cell Phone: 3f g 3 ZZ 5-tIO'3 (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) '3- / £s -`Lz�, l b. Taxicab Business Name (REQUIRED) U 2,�H„n (cn;x e (?p,,(j 5. Prior experience in transportation of passengers: VQ S MAR 1 j 21116 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 Suspen Other 7. Have you been arrested /charged with any traffic offenses in the last five years? A/d Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 1�6 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) 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby cerci that have issued to me by the Iowa D partm nt of Transportatiop veli Chauffeur's license number Li % �,f ©2�� issued on6 2,Ln / 3 expiring on 11 f% if j 4; . 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 provision fT�lC, Ch pter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Dates" iilr STATE OF IOWA ) COUNTY OF JOHNSON ) �ubscribed and sworn to before me by A, r to Q,,, 14 A& G r,' h on this / —1 day of th- � I have reviewed this application, DCI report, and the State certified driving record of this applicant and havEp€leter in there is no information which would indicate that the issuance would be detrimental to the safety, health orr lr ofP dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Chauffeur's license 9�/s'�/� MAR 17 1016 City Clerk Iowa City, Iowa Sign ture of PoliceXhief 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. Signstu e of City Clerk or designee Jam. -L Office Use Only Approved application DCI report State certified driving record Website update 31171 �� Date ClerkrrAXIDRIVBADGE PPL92014.mended DOC 03/2015 61aor "AV Iowatttat.gov SM14TEEI'I"rN FICUSTOMb F��RIYH �..,._.._ Office of Driver Services PO Box 9204 Des Moines. IA 50306-9204 Phone: 9-15-244-9124 1 A00 -532-1121I Far,: 515-235-1837 www. iawadot.00v Inquiry Date: Customer Name: Address: Certified Abstract of Driving Record 3/3/2016 DL/ID #: 679AJ0237 (IA) CDL Permit Class: None 6073198 Class: B Sharif, Ayman Mahmoud Audit #: 7062538 Mohamed 1901 GRYN DR Issue Date: 06/22/2013 City/State: IOWA CITY, IA 522464408 Mailing 1901 GRYN DR Address: Mailing City/State: Date of Birth: Sex: Convictions IOWA CITY, IA 522464408 9/18/1967 M Expiration 09/18/2018 Date: Endorsements: PS CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: 09/27/2013 CDL Permit None Restrictions: ELG ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: VAL Supplement: 09/27/2013 S92 Speed CDL Permit ELG 33/08/2014 Status: S92 Speed (10 mph & under in 35-55 mph zone) CDL Cert Status: Excepted Intrastate ]1/25/2015 CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County JUR 09/01/2013 09/27/2013 S92 Speed 33/08/2014 04/08/2014 S92 Speed (10 mph & under in 35-55 mph zone) Johnson Johnson IA IA ]1/25/2015 04/14/2015 S92 Speed Johnson IA Name: Sharif, Ayman Mahmoud Mohamed DL/ID: 679AJ0237 Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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: 3/3/2016 Feb25, 2016 4 : 0 6 P M D l v of Crim nal Investigation NoE311 P. 3;'7 Frem;Clty of town City Clerk Olfloo 31E 3666407 02/24/2010 16:43 N417 P.002/002 F pin m A X Il��t�WtCriminnil History1 r' C �t -Request Forni TO: Iowa Division of Criminal hivest(gatiou Support Ciperafions Bureau, 1" Floor 315 E. 71h Street Des Maines, Iowa 50319 (515)72,5-6666 (515)725.608D Fax am requesting an Iowa Crim Last Name (mandatary) rN y�O`� Late of pslrt—h(mandatary) "I-pis-Iq6-7 DCI Account Number: Z) Z f (if applirnble Frctsa: Cify of Iowa City _ City Clerk's Office 410 E. Wtishblgton Setcet Iowa City, IA 32240 Phone; 319-356.5041 rax; 319-356-5497 El Male ❑Female Name Moa -\m0�di cial Securifv Numh Ge)(& 5eF ci-76(� WalpW' Infornmiion: wilhoat a signed waiver front the subject of the request, a ooraplue criminal history reenvd may not be releasable, per Code of Iowa, Chapter 692.2, For complete crimina) history record information, as allowed by law, always Waiver Release: I hereby give permission for ilm above regaessing aKcisl to conduct alt lowa ctiniinal hi story rccosd check with the Division orcriminpl 11wesif9mion (DCI), Any criminal history data concerning me Ilial is nWMained by Vie"DC1 may be released as allowed by law. WeriVer'sfgnalure; Iowa Criminal History Record Check Results ' (Dc,sea„ly) w� � As of , a search of the provided Warne and dale of birth reveal�ii: PQ n t No lown Criminal History Record found wi111 DCI �}� 'rr , .=s ❑ luwa Criminal History Record attached; DCI 9 DCI Ul7-// (Ut/25110) Re. re i v p d 7ime Feh. 94- 9016 9:11 PM No. 8174