HomeMy WebLinkAbout16-160CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
1319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. I Le — /[-00
(Office UOnly)
APPLICATION FOR TAXICAB I 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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2. Address (REQUIRED) P- 9;.9-4 I-V R1) -;9k,2 W !�-4o We'l t y i A %52 2 u
3. Contact Information (REQUIRED) Email: J2Qo(a� ) 4 `Ao'hvt 1\ t C C9 wt Cell Phone Iq � 32�T � -3
(All written communication sent via email)
4a. Driver's License expiration date (REQI
b. Taxicab Business Name (REQUIRED)
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? /✓o
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? X71 y P S
Type of offense Where W hen -
S�eeJ C04CI0 a2/o6/90 Iy
VA CLIdP- VaLU'lI k (')i, -2/ 70 12
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? ,/1/ is
Type of offense Where When
N
O
9. Have you ever applied/to be an Iowa City taxi driver using a different name? If yes, pleasekiotFde tke nanms
/ V d N
_ IF a
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATI= CEIEDI
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEFAEVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
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APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I herggby czrtfy that I h@ve i sue( to me by the Iowa Department of Transportation a valid Driver's license number
issued ono2/�.V9oI6 .expiring onI understand that if I
falsely answer any questions in this application, that this application may be denied. Il agrehi�aking this application, 1
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 U� DateO2/ 9 9 9s I C
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by�)e. L dy C.. /�'ta W � c. on this ZZ 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 Driver's license
Signature of Police Chief or designee
P,12,ql-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.
Sign e of City Clerk or designee
9/o�oZ //�
Date
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Office Use Onlyv C=
D- G
=- N
—i4 CC- i ri1
Approved application �-P.
DCI report
State certified driving record
Website update Y p
X77.
GaM/7A%IDRN94DGEAPPL92014amentl DOC 07/2016
Fr�HUg. IL. LU Ih,,, 9UAMLleekUlv of Gr lml naI Inve st lgat loo oeioaigo+a: +e:e No. 153,6816 P, loarooz
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PCheck
Criminal
rdt
� Request
I
To: 'owe Division of Ca•Imhral Investigation
support Operations Bureau, I" Floor
215 E. 7'h Street
Des Moines, Iowa 50319
(515) 725-6066
(SI 5) 725-6080 Fax
Lam
DCI Account Number: _ co -L "ice
(if applicable)'
From: Cit oflowacity
City Cleric's Office —
410 E. Washinglon street
Iowa City, [A $2240
Phone; 319-356.5041
Fax: 319-356-5497
Ftbcilk d1ct �1GCIY) hew,"f'�11�
Value of Bri�rth b,nndaroM Gender (m ldaln l Social securi oumher (recommended)
d I ` G ^ t ,� -Male ❑Female p
Waiver Inforntafio►tr Without a signed walver from the subject of the request, a complete criminal history record may not
be releasable, per Cade of Iowa, Chapter 692,2. For co_ mDlete ctyminal history record information, as allowed by law, always
obtain a waiver si nature from the subject of the reouect.
A`a1Ver ReieaSe: I hereby give pcm,ission for she above rellucsting 0111,621 10 conduct an larva criminal hrnory record cheek %iN Ilm Division of Crio,in i
Invesligallon (DCO. N,y eriminai hislop' data wneeming me that is maintained by the bc, maybe released as 0110wtd by laiv.
Waiver Signmirn. Y—.Z,.>/ Dr"k 1,
Iowa_ Criminal History Record Check
F5�1
only)
As of _� Z-��LL a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI MF, L7}'
❑ lowa &iminal History Record attached, DCI #
DCI initials a
c• ,t c7 �it
DCI -77 (08/25/10)
Received Time Aug 9, 2016 4:28PM No. 1262
Page 1 of 2
Cl�DOT
SMART www,iowadotgov
ER I SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-11211 Fax515-239-1837
www.iowadol gov
History Information
Convictions
Citation Date
Conviction Date
Certified Abstract of Driving Record
Explanation
Inquiry
8/18/2016
DL/ID #:
459AF2353(IA)
CDL Permit Class:
None
Date:
IA
Customer
5741899
Class:
D
CDL Permit Issue
None
#:
Date:
Name:
Abdalla, Jalaleldin
Audit #:
8841421
CDL Permit
None
Rahemtalla
Expiration Date:
Address:
2525 BARTELT RD APT
Issue Date:
02/12/2015
CDL Permit
None
2A
Endorsements:
Expiration
04/25/2020
CDL Permit
None
Date:
Restrictions:
City/State:
IOWA CITY, IA
Endorsements:
3
ID Status:
None
522462718
Mailing
2525 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:
522462718
Status:
Date of
4/25/1974
CDL Cert Status:
None
Birth:
Sex:
M
CDL Med Status:
None
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
01/28/2014
02/06/2014
S92
Speed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
12/08/2013 1,773179 IA
Name: Abdalla, Jalaleldin Rahemtalla DL/ID: 459AF2353 -'-,-� -y'y
Pursuant to Iowa Code 4321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Dep mint o"ranspbrtation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this ise e and accu Deb of
an official record currently in the custody of said office, and that I have been authorized by the DlrectIIr`Qfsjhe Vigra Departr,�ent of
Transportation to so certify. ----,, _Q
In witness whereof, I have caused my signature and the seal of the Department to be set upon this documentot Ankeny, Iowa
this date:
�rFlUClf ®j6i 4.
8/18/2016