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HomeMy WebLinkAbout16-138i w ts cccccril -k A"Milm- CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-182 6 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. 1 (-' � (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) y6 Email: &J YU ^ C) S i -✓l A 0 - V SGI (0, Cell Phone: A 017;; 5"12-8 (All written communication sent kvia email) fh I I L _ c c, V*'� 4a. Driver's License expiration date (REQUIRED) © ! IG 1 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6 T 'y.p O V S' — 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? JVO Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When Other When Convicted Dismissed Deferred Suspended Plead Guilty Other - NIn 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 name(s) j 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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I �ereby6rtify that I have issued to me by the Iowa Department of Transportati n a valid Driver's license number O (Vj 03 l4 o issued on x,,611,4 expiring one, G I understand that if I falsely answer any questions in this application, that this app icaatio>n ay be denied. I agree t at 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, oftheCity Code. (Needs to be signed in front of Notary Public) Signature of Applicant"/f Date 8 1,6 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by raS,Ccoy� on this day of A_ " . < -t- moi-,/ f o 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 Driver's license Signature of Polil Chief or designee W2/ZZtj- 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. �GC�i�i a✓ )� - r� Signatu'rb of City Clerk or designee Approved application DCI report State certified driving record Website update Date �T Office Use Only i cn GeBI IDRNBADGE PPL92014amer,ded.o C 0712016 Hug. 1. 2010 113Nmi Div of ClimInaI InvestIgatIon No.9540 P. I Fl.,n.!..i,y` u. Iowa �,,y Clor Y. m —m— 07/26/2016 14:4. —690 .,,02/002 S YATE OF IOWA sy (Criminal History Record Check 'q Request Form C �� 4u DC1 AccotmtMuoltfer: (if eyylicable) w Iowa Division of Criminal lnvesligalio) Support Opera Cions Bureau, I" Naar 215 11. 71" Street Des molnes, Iowa 50319 (515)72:5-6066 (515)'125-6000 Fax I am mauestine an Iowa Criminal History Record Check on: From: Cityof Tocva C¢C9_,____, City Clerk's office 410 E. Wahing(on Street Iowa City, IA 52240 )?hole: 319-356.5041 Fa Y.: -- Last Name (mandatory) rirst Mame onandalory) Middle Name (,ecmnmcaded) aSSa�r �' S wN cj� v-� Vv'� e h Ned ]sate of Birth (mandmoly) Gender (mandatory) .Social $eeuri(, Number (retomamnded) I 7a ,.lJ�'I., rr La)e El Female Ll"— 9ci — 2.973 o v)R_ q G Ci Waiver Information. Without a signed waiver from the subject of the request, a complei o criminal history record may not be releasable, per Code of Iowa, Chapter- 692.2. For complete crlminal history record information, as allowed by law, always obtain a waiver signature from the sub'ecl of the request. Waiver ReleoSe:l hcrcbygivc pumission for the abmc rgmming official to COMIOM m lewacriminal hislory record cluck wilh the Divisim ofUn aal Grvesligalion (DC,I), Any errimi al history dam wnc ming me Thal is mtalntained by the DCI gray be relcosed as allmed by lay. Iowa Criminal History Record Check Results (b�tso only) As of B 1 ZI �� a search of the provided name and date of birth revealed: r— — No Iowa Criminal I3istury Record found with DCT Q Iowa Crimiml History Record attached, DCl # o "n XT initials DCI -77 (08/25/10) Received Time Jul. 29. 2016 2:29PU No -0589 Page 1 of 2 C 4001 lJ10WADOT www,i©wadot.gov SMARTER 15 IIMRLEA i CUSTOM EF DRIVEN_�..,;,,,,�e,�,,,,�;,,�,,,�,,,,;.....�.�„ Office of Driver Services PO Box 9204 1 Des Moines, [A 50306-9204 Phone: 515-244-9124 1500-532-1121 1 Fax 515-239-1837 wwwiawadol. gay History Information CLEAR DRIVING RECORD Name: Hassan, Osman Mohamed DL/ID: 103AM0320 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: '.ENICLC p�`y Certified Abstract of Driving Record 7//2x99///2016 i Inquiry 7/29/2016 DL/ID #: 103AM0320 (IA) CDL Permit Class: None Date: e.'. Iowa Department of Transportation C_ri Customer 6474944 Class: ❑ CDL Permit Issue None #: Date: Name: Hassan, Osman Audit #: 1136076 CDL Permit None Mohamed Expiration Date: Address: 2404 BARTELT RD APT Issue Date: 07/08/2016 CDL Permit None 2A Endorsements: Expiration 07/08/2021 CDL Permit None Date: Restrictions: City/State: IOWA CITY, IA Endorsements: 3 ID Status: None 522462704 Mailing 2404 BARTELT RD APT Restrictions: NONE DL Status: VAL Address: 2A Restriction None CDL Status: None Mailing IOWA CITY, IA Supplement: CDL Permit ELG City/State: 522462704 Status: Date of 7/8/1970 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Hassan, Osman Mohamed DL/ID: 103AM0320 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: '.ENICLC p�`y 7//2x99///2016 i IOWA s; 7f QAIj S- Office of Driver Services e.'. Iowa Department of Transportation C_ri Name: Hassan, Osman Mohamed DL/ID: 103AM0320 7/29/2016