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Home My WebLink About16-167MIS®i�,l CITY OF IOWA CITY 4 10 East Washington Street Iowa city, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. — 107 (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) Email: -0M 7 (� xaS1n', 0.2)v�'(6" Cell Phone: (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) D-? / / '] r) 11 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?vo 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? /Q C) Type of offense What happened to the charge? (Circle one) Where When 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? N U Type of offense Where When N 6 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please ptnvide thfAame(s)•- n t - ' (11 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 f APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number 5 L4 oi A G � h2 issued on Lf /IN / I6 expiring on S/1/, /.Z 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 Ay f Date�3 Z 2 5 / iiiflfll1111Mfll11flf1R####f+#+#iiYii#Yiif111fllflf!!f}#11111lf}ff*}}+}4+i4fi-#*!4f!!1f!!1fllflfYff}}fffi4+#f}*}441Hi#fiflf11fH11111Mfifllflf STATE OF IOWA ) COUNTY OF JOHNSON ) Su scribed anI sworn to before me by A►Ka.6' 6c_4 n 5-g5t i.A on this Z� day of 7,0 ��000 E. NAYER Notary Public wa and for the State of how M-0 Nfikklt#11fi4ifile'Iffeffift*,YRffill!lflifllfltli+tfiffiftfiltlt+*iltlfiil,flMlifH*f#fYf1441'fiif4ilfill#ilfiiNllM#Mfi'1*f!!#MRkkf iffmltflRiifttii*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). ll's license 6/Z &Z or designee —Ate '�— 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. ..,) .k . t"2 Signa re of City Clerk or designee Date mi4iiifrlfYferf:ffflrlrrrrrrlrrlrrlf+rff+++4ef++lrrrlrrrrrrrrlrrrr+r}.f}+}4+++iiY»rrf:rfrrrrr:rrrrrlrfr}fflffiiiiiiei++l+lr+!l+lrrlrrrrrlrrrr N C� Office Use Only _.}, Approved application cn DCI report ?..� State certified driving record Website update Gen<rrnxIMVBADG�Ml4s�.DOC 0712016 Aug. ll. F! 2016 ••2:47PM Div of Criminal Investigation No, 0838 P. 4/6 "••'-"••• "• .,.e ------ 06/16/2013 14:S. 460b 1.--3/002 a,�`yalar.r 4` STATE OF 1 0. 1 y Itwn Criminal im History r t tdCheck Request Form t To! Iowa Division of Criminal hivesligation Support Operations Bureau, l" Floor 215 E, 7" Street D99 Moines, Iowa 50319 (515)725.6066 (515) 725-6000 Fax DCI Account Number; Lf0 0 2, —1-- (if appnaehle) Front c)ry orfova city City Clerk's Office 410 V. Washinatoa Street Iowa Cit , TA 52240 Phone: 319-356.5041 Fax: 319-356-5497 -rr .Il�nwrn >Ilrsr r ame manaalon9I Middle Name (rewnmlended) G ��osa5�l A-4.,\ cof � min5f �Ff� to social ch4ale rli?emale IG9�-1(4-3g o"1 Walver Mforrnarion: Wilhout a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of tows, Chapter 692,2. For comate criminal history record information, as allowed by law, always obtain a lwalver sionature from thr nl hi..l .rih......,... Waiver Release: I hereby give permissioo for rho abm•e requesting official to eenducl an lowo Criminal hillary rccold eked: with the Division of Cdroinel luvestigstlon (DCI). any criminal hislory dam wneerning me Thal is malmaincd by the DCl may be releasta as allowed by law. Waiver .Si nalttre; Iowa Criminal History Record Cheek Results As of 5A44 -1 a search of the provided name and date of birth revealed: NO Iowa Criminal History Record found with DC1 ® Iowa Criminal History Record attached, DCT # DC1 initials__ DCI -77 (OS/25/10) Received Time Aug. 151 2016 2:21PM No. 1103 (DCI use only) I ClJ10WADOT SMARTER 15IMPLER I CUSTOMER DRIVEN WVVW'IOWBdOt gOV Inquiry 8/25/2016 Date: None Customer 5876365 Endorsements: Name: Elgorashi, Amar Restrictions: Elmustafa Address: 2504 BARTELT RD APT IA City/State: IOWA CITY, IA 522462714 Mailing 2504 BARTELT RD APT Address: IA Mailing IOWA CITY, IA City/State: 522462714 Date of 3/26/1984 Birth: Sex: M Office of Driver Services PO Box 9204 I Des Moines. IA 503069204 Phone: 515-244-9124 18DD-532-1121 I Fax: 515-239-1837 wwwmwadol.gov Certified Abstract of Driving Record DL/ID #: 549AG7752 (IA) CDL Permit Class: None Class: D Audit #: 9946280 Issue Date: 04/19/2016 Expiration 03/26/2021 Date: Endorsements: 3 Restrictions: Corrective Lenses Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Elgorashl, Amar Elmustafa DL/ID: 549AG7752 CDL Permit Issue None Date: CDL Permit None Expiration Date: None CDL Permit None Endorsements: CDL Permit None Restrictions: Iowa Department of Transportation ID Status: None DL Status: VAL CDL Status: None CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None 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: :•"••••'•7:�'(�"4 8/25/2016 Iowa' *w,. p l y �Op ;f o D. 0. T,, , f ^•••'•• "' Office of Driver Services Iowa Department of Transportation Name: Elgorashi, Amar Elmustafa DL/ID: 549AG7752