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HomeMy WebLinkAbout16-122r IDENTIFICATION NO. Q — J 7� _ (Office Use Only) It J10aW- CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email: ov N-� ? �5 e\ °nab M x Cell Phone: 31 y,.`Z ( a -JI �3 (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) _ \ a -J'-' oAN1 kCAI 1 07A 113 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 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,rvame(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 upop request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) v 02/2015 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilt Other 7. Have you been arrested / charged with any traffic offenses in the last five years? M© 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? 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,rvame(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 upop request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) v 02/2015 APPLSCATION 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 ��,, n a ��Z 1n I sued on expiring on a�_7 _ 2 �(k, I understand that if I fa e7y answer any questions in this application, that this application m y 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 `LS — A_ / 6 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn r to before me by L4dnn,4� 0. ,55 on this 2 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). kiodat au eur's licensePo c i 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 Office Use Only Approved application DCI report State certified driving record Website update Gleik/rAXIDRIVBADGE PPL92014amendedDOC Date „,Jun, 2-/. 2016w 9:12AMG1ark o Criminal investigation 06/21/2016No. 8343 l` 1 }J;O_ ..662 ..,02/Db2 g"ll`ATE OF IOWA Crriaxeinal History Record Check Request Foran TO; fowaDivision of Criminallnvesiigation Support Opera lions t3nreau, 1" Floor 215 E, 71” Street M Moines,Iowa 50319 (515)725-6066 (515)725-6000 Fax I am requesting an rowa Criminal History Record Check an: 17C1 Account Number: (il'applicahlG) From: City of Iowa City City Clerl('o Office 410 E. Washington Street fovea Cir , lA 52240 Phone: 314-_356.5041 rax: 319-356-5497 Last Name (mandatory') - Fust Nan1e (maodatory) Diddle NamC (recOmmardcd) `Number Date of $irtb (mandato y) _ Gender (mandatory Social Security (recommended) `-- �� •, � �� Male Female Waiver Information: without a signed waiver tram the subject of the request, a comptele criminal history record may not be releasAble, per Code of Iowa, Chapter 692.2. For cornolete criminal history record lufmrmation, as allowed by law, always obtain a waiver signature frow the snb.fect of the request. Wal ver.Release: 1 hereby give 0 mnission Por 110 above regvesl ing ofrrcial to conduct ail Imva criminal IINOry record check wide the Division of Criminal Investigation (DQ. Any Grlmilml histoty data concerning me Thal is maintained by the DCI may be released vc allowed by law•, WalverSignaltere: �(`r\O�Gw.@� ��SC.,�� Iowa Criminal History Record Check Results (DCI use only) As of —� L. , a search of the provided name acid date of birth revealed: No Iowa Criminal History Record found with DCT L'. ® Iowa Criminal History Record attached, DCT ti 0 PO DCT ilildals—1 v — Ul:!-Y! (0;/15/10) Received Time Jun 21. 2016 4:50PiM No.8044 CJ10WAD0T SMARTER I SIMPLEP� i CUSTOMEF DRIVEN W1NW,IOWBdCY�.C�04 Inquiry Date: 6/28/2016 Customer #: 6268742 Name: Hussin, Mohamed Ismail City/State: Hamid Address: 2654 ROBERTS RD APT 1D City/State: IOWA CITY, IA 522462741 Mailing 2654 ROBERTS RD APT 1D Address: D Mailing IOWA CITY, IA 522462741 City/State: 06/24/2016 Date of Birth: I/1/1983 Sex: M Office of Driver Services PO Box 9204 1 Des Wines, IA 50306-9204 Phone: 515-244-91241800-532-11211 Fax: 515-239-1837 www lowadot.gov Certified Abstract of Driving Record DL/ID #: 840AK8261 (IA) Class: D Audit #: 1104971 Issue Date: 06/24/2016 Expiration Date: 01/01/2019 Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: Office of Driver Services CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number 7UR 02/02/2016 910757 IA Name: Hussim, Mohamed Ismail Hamid Dill 840AK8261 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: +"••"•;'�%'ry 6/28/2016 IOWA yF "•'•••5�= Office of Driver Services Iowa Department of Transportation Name: Hussin, Mohamed Ismail Hamid DL/ID: 840AK8261