HomeMy WebLinkAbout16-159a r d
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 3S6-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. � 6`
(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
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3. Contact Information (REQUIRED) Email:
(All written commuhica'tlon sent
4a. Driver's License expiration date (REQUIRED) 6 1 D % - 7_9
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: cS I to bp -
Phone:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? N 6
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
r � e
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended lead Guilty Other /
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?„. !i y
Type of offense Where 'When "5
_y.
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
/J n _a
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 hereby certify at I ¢ave issued to me by the Iowa Department_of Transportation a valid Driver's license number
SZDg R6S/ issued on oi,o vllexpiring on ol•cI 2oV� understand that if
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)
v �
Signature of Applicant Date 6$'
STATE OF IOWA )
COUNTY OF JOHNSON )
' scribed and sworn to before me by f2,l� tv I lA_ on this 1GI I day of
KELLIE K. TU �`� f L
d Camrni�siun Number Public in and for the State of Iowa
res
o c-
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 li n e
SIgnature of Flolice Chief or desi e
q 12 olA
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.
Sign ture of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
q
Date
M1�
ClerkFFA IDRIVBADGE PPL92014amendea.000 07/2016
F Aug,18, 2016 12:30PV oil"Div of Criminal Investigation No, (932 P. 2/2
• •�-- •-••�--•----. 08/16 /20nG 11:.— –62e, w.vva/002
S'S'A u E Or, 1[OWA
Q."lriiunnrmaB Hktory Reco,><dl Check
Requeaf Form
TO: Iowa Divisicyl of Crimtna) Ii.vestiga lion
Support opera(iml.s Bureau, I" rlaor
21.5 R, 7'a Street
I1esWines, Iowa 50319
(515) 725-6066
(515)725-600 rax
tale requesting an Iowa Criminal Histoi_v Record Check on
DCl Account i`lunalier: q n-7, 2�--"
(if nppliczhlc)
Flom:Ci1y ofIowa Clty
City Cleric's office
410F. WaANgioh Sheet
-Iowa City, IA 5224.0
photic: 314-356-5091
Fax; 319-356,54)7
JLasttNance (n,andaln ) First Name (mendalory) Middle NAine (recommended)
k
Y3ate Oi Birth (mandatory) Gender (manda[ory) Social Seeuri ' Niinlber recommanded
4I GI I97�S~ tKRTale ❑l+etnale ��i q_ 1Z--- S 2-Z—�
GYaiver IriformaLio r; Wt[haut a sighed waiver from the subleet of the request, a conIptete criminal history record may not
4 releasable, per Code of Iowa, Chapter 692.2. For Complete er"ll"i history record inf0rraatioey as allowed by tare, always
obtain a N•alVCr gieneture f rpm the mhiaA of Cho
WriverR@(@ffS@:Iherbygive permissionfor rheeboverequcsGngof cislloconduetantowncriminalhisturyroeortlelrekreifhthcbirisionofCriminal
lnvea[igoden (DCI). Anycriminal hirmrydaraconcerniugmclIm lsmaiateinedoy the DCl may be released ac allolecd by lew.
MallverSLa lafure:
Iowa CriIIIi�1�1 Hzstory Iteeord Check Result
(DC] nap mdy) ,
As of ��� a search of the provided name and date of birth revealed;
No Iowa Criminal History Record found milli DCI
Iovx a Criminal History Record attached, DCI # (';
DCT initials c
DCI -77 (08/25/10) — x
Received Time Aug. 16 2016 11:00AM No. 1760
Cwt=410 DOT
SMARTER' I SIMPLER I CUSTOMER DRIM vva'dt7t gC]V
Office Of Driver Services
Po.Box 92204 i Des kinins. IA 510306-9204
Phone: 515-2449124 f 8DO-532-1121 I RP xi 51&239-1837
wv ,tovradct.gov
Certified Abstract of Driving Record
InquiryDate:
8/3.0/016
DL/ID #:
809AK8656 (IA)
CDL Permit Class:
None
Customer #:
6227659 ' "
Class:
D
CDL Permit Issue
None
Date:
Name:
Kirja, Karl Hassan
Audit #:
9403765
CDL Permit
None
Expiration Date:
Address:
1913 GRYN DR
Issue Date:
09/08/2015
CDL Permit
None
'
Endorsements:
Expiration Date:
01/01/2019
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522464408
Endorsements:
2
ID Status:
None
Mailing
1913 GRYN DR
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522464408
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1975
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
ate Conviction Date ACD Explanation County ]UR
5 �4/21R015 'M14 IFail to Obey Traffic Sign/Signal L3ohnson iIA
Name: Kirja, Kamil Hassan DL/ID: 809AK8656
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I an
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 o
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:
8/16/2016
IOWA . z%G
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Office of Driver Services
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Iowa Iowa Department of Transportation
Name: Kirja, Kan -11 Hassan DL/ID: 809AK8656