HomeMy WebLinkAbout16-073l - 1
CITY 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(' — 07
(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
Middle
3. Contact Information (REQUIRED) Email: Gb&D sL�kl—Al COM Cell Phone: 5 1 736 16 Ck'
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 11 " 177 - D 19
b. Taxicab Business Name (REQUIRED) Nit 11 HDO ON "u- 2 i d2.,
5. 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
lsewhere?_Type of offense Where When
DEFT lot �A CITY— -
I 1C)t r2ot4
What happened to the charge? (Circle one)
Convicted Dismiiss d Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? NO
Type of offense Where
When
What happened to the charge? (Circle one)
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? Nn
Type of offense
Where
ru
When
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please proufdethe name(s)
i
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE-CERTIRBD
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
eMI�ereb ce tify that have issued to me by the Iowa Dep ment of Transportation a valid Chauffeur's license number
T 'R � 7 issued on �wexpiring on I I I l - I q . 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 , of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date-% 16411 fj
STATE OF IOWA )
COUNTY OF JOHNSON )
sworn to before me by A\ � c j/lx � on this 9 day of
—
Public Wand for
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 Il IS
j J L,(�n a
Signature RWolicerhlef 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
"i�� //,"
Date
Office Use Only
0
Approved application -
DCI report `-
State certified driving record
Website update a
r
Cil
cien<r AX1DRroeaoceAPPre2oiaamendea.Doc 0312015
Ma r. 30• 2016 9:36RN Dlv of Crim nal Investigation No. 1018 P. 5%6
FY. Ol art. �.. .. ..... ...... ..—.,, 03/29/2016 14:6o ♦yank r.vv2/002
STATE OF IOWA
0 Criminal History Recard Check
Request Form
To: Iowa Divlsicn of Criminal Invesjigalion
Support Opurabons )Iurea4, 1"Floor
215 11. 7'4 Street
lies Moines, Iowa 50319
(915) 725-6066
(515)725-6080 Fax
am requesting an
IC5RANIM
Ate Ofliirth (maadeloq•)
II - I�- 1991
DCJ Account Number: t(dp
(ifapplicahlc)
Crory: (it of Itwa CII
--
City Cleric's (]ffice
410 C. W4ashhon Street
Iowa City, IA y224U
Phone: 31y-336-5041 _
Pax: 314-356-5497 � '—
Record CJJeCk on:
1~i1'A Nanle (mandstory) _
A A D C) (A R A Z,4 C-
V —"
,el' (mandalory)
�Ivlale ❑Fenfale
0$0 02 JggG
Ifalver Llzfo/"htaf%oft., without a signed waiver from the subject of the requesi, a cmnplete criminal history re�-- eoraroay not
be laiYeln
aswaivnble, pet• Code of lou'a, Chaplel' 692.2, For -Coro Mote criminal history record in formailon, as allowed by late, always
oLlain a waiver si nature from the subject of the reaueo.
Waiver Release: I hereby give pem+ission for the ehove requesting ofcial to conduct mr Iewa criminal history record cheek with the WVISiDA of Criminal
hwesl igati on (DCO, Any edmirpl hist my data eoncrrnina me Ibx1 is maintnincd by the DCI map be rclCBsed as allowed by fam
WaiverSignatffre:
IMP Crimillaii History Record Check Results
� ��i hue anlf)
As of
, a search Of the prgvided name and date Of bill]) reveal-;
No Jown Criminal Hista,p Record found tajith DCI
Ioura Crirninal His(oiy Record attached, DCl #
DCI iltiiials�_
DCI -77 (08/25/10)x~ -�—
Received Time Mar, 29. 2016 2:43PM No. 0943
ARTS Page I of 2
C1410 WA DOT
WVif%NJ, I o'if if Lel c ot. q 0v
SMARTER 1 SIMPLER I CUSTOMER DRIVEN
Inquiry 3/18/2016
Date:
Customer 6057823
Name: Ibrahim, Abdou Razac
Address: 21 DATA DR
City/State: IOWA CITY, IA
522403010
Mailing 21 DATA DR
Address:
Mailing
IOWA CITY, IA
City/State:
522403010
Date of
11/17JIS91
Birth:
None
Sex:
M
Offiea of [trivet Service's
PO Box 9204 1 Cres F7rOfE3••.es. IA 5,OW,3 32G4
Phoi 515-244-9124 1 80C-63:.-.129. 1 Fax' 51a-233-1837
Certified Abstract of Driving Record
DL/ID #:
66BA18167 (IA)
CDL Permit Class:
None
Class:
D
CDL Permit Issue
None
Date:
Office of Driver Services
Audit tf:
8222047
COL Permit
None
Expiration Date:
Issue Date:
07/02/2014
CDL Permit
None
Endorsements:
Expiration
11/17/2018
CDL Permit
None
Date:
Restrictions:
Endorsements: 3
ID Status:
None
Restrictions:
Commercial Learner
DL Status:
VAL
Permit
Restriction
CDL Instruction Permit
CDL Status:
None
Supplement:
Expires 12/27/2014
CDL Permit
ELG
Status:
CDL Cert Status:
Non -Excepted Intrastate
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Ibrahim, Abdou Razac DL/ID: 668AJ8167
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:
.............il
3/18/2016
IOWA.T..:
�
D. 0. T.,�1�„
7......... `u�'
Office of Driver Services
4a��wr���
Iowa Department of Transportation