HomeMy WebLinkAbout16-081� r 1
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CITY OF IOWA \\\\\CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. 16— CG (�
(Office Use Only)
APPLICATION FOR TAXICAB 1 MOTOMZEb 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: Sam, -(229310 L h ,c--„ Cell Phone:
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
o\ �6
b. Taxicab Business Name (REQUIRED) � / wJ U /\, j�2
5. Prior experience in transportation of passengers: 1 'l eq r-4
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? I/ f
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?
/ (o / A-, n
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? 0 I tl
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 Department of Transportation a valid Chauffeur's license number
b n a `h issued on 1 1 o� I AQi3expiring on ^ o I % . 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_T_ =� Date -L -1 -LL I� o I b
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by J 5 ^' r u on this ( 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 i 1 � U
�7 4
Signatur o ice Chief or designee
`6
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.
gn ture of City Clerk or designee
Office Use Only
Date
4w_
Approved application
DCI report
State certified driving record
Website update
ClerkrfAXIDRIVEADGEAPPL92014a.ended.DOC 03/2015
Page 1 of 2
CZ10WADOT 1 1++?`r`iEr; I CtiSifl'�ER DRIVEN
AAAAy,it,w�tdot,gnv
Office of Dr FVer Servo: es
FO Bos; 8294 I Des Moines, IA 5330E 920+4
Phone: 615-244-9124 1 a00 2A 12 1 1 Fa 5"5 -234 -Pi
History Information
Convictions
Citation iOate
Conviction Date
Certified Abstract of Driving Record
County
inquiry
4/14/2016
DL/ID #:
266AD7808(IA)
CDL Permit Class:
None
Date:
11/25/2009
S92 Speed
'..Johnson
'IA
01/28/2012
Customer
5429309
Class:
D
CDL Permit Issue
None
#:
Date:
Name:
Ali, Samir Isameldein
Audit #:
7504999
CDL Permit
None
Expiration Date:
Address:
2427 BARTELT RD APT
Issue Date:
11/06/2013
CDL Permit
None
2B
Endorsements:
Expiration
11/03/2018
CDL Permit
None
Date:
Restrictions:
City/State:
IOWA CITY, IA
Endorsements:
3
ID Status:
None
522462710
Mailing
2427 BARTELr RD APT
Restrictions:
NONE
DL Status:
VAL
Address:
213
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA
Supplement:
CDL Permit
ELG
City/State:
522462710
Status:
Date of
11/3/1985
CDL Cert Status:
None
Birth:
Sex:
M
CDL Med Status:
None
History Information
Convictions
Citation iOate
Conviction Date
ACD Explanation
County
JUR
08/28/2009
10/16/2009
S92 Speed_
'.Johnson
SIA
09/09/2009
11/25/2009
S92 Speed
'..Johnson
'IA
01/28/2012
04/04/2012
Improper Parking on Highway
'Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number IUR
07/27/2012 696745 SIA
Name: Ali, Samir Isameldein DL/ID: 266AD7808
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 ar&accurate-c6py 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 documi:nt,-ak Ankehy,'Iowa
this date:
4/14/2016
`••""""'•;�/�4�
•
4/14/2016
IOWA , w,,
.n,/J%.�..
Of
Office
UBI1fE4
of Driver Services
Iowa Department of Transportation
Name: Ali, Samir Isameldein DL/ID: 266AD7808
Page 2 oft
4/44/2016
PApr.12, 2016, 4;12PM Div of Criminal Investigation No, 1654 P. 1
Ole . .. _...__ -. 0n/'1/2016 13'u. W48G x.002/oo2
,,,if JJ,i•bR� STATE OF IOWA
3elyACriminal History Recoyd Check,
Request Form, p.Y
y(
To: IOWA Divig(oll of 0,11ninil Investigation
Soppart 010crations 13urcau, I" F(oor
215 C. 71, Streo
Des IrIo(ness I(Jyva 50319
(513) 729-6666
(515) 725-6050 Flax
am requestin au
L.9stNamr
Record (
First N
DO AccountNuulber' 4GO?-�
IIt UI1Id IC361C1 •—
('root; -g!tK of lalV& city
City Clerl0s officr
-410lr. Washington -Fred
Toiaa C1ty, [p 5224U�_
Phone; 319-356-5041 -
pa)c: 319-356-5497 _-- — -
r 1i �an�(�
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bate of Birth (mendalen.) Gender' (mandatory)
l � cunei/alSectin '1Numbel-t-- ...... l
l 0317hfale ❑Female I QU-�� �6 L--1
Waver Xnforr lalivrr; Wifhout a signed Waiver fano the sublec(of The request) h cornDlefe criminal history record may not
be feleasnble, per Code of Iowa, Chapter 692.2. For complete criminal history record Information, as allowed by law, Always
obtain a waiver si na(ure from the subject of the reauest.
Waiver Release. I hereby give pemlistion for the above regnteling official to condom an Iowa eriroinal hiskin ,cord cheer: "rill, (Fm l)ivisior orcriminal
hives ugation(Dc)). Aly criminal history dale concercdn�me lhalismaimalued byUu DClmaybereleacedasellolyed bylaw.
Waiver Signature:
It3Wd Crixflinal Histoa Record Check Rcsuits
search of the provided name and date ofbirlh tev,ealc d.
No Iowa Crilnival 1listory Record found uilh DCI
❑ Iowa Criminal Mislay Record al(ached, 1)01 #
LJN
DCl initials —
`00-77 (08/25/1 o)
Received Time Apr. 11. 2016 1 27PM No, 2074