Loading...
HomeMy WebLinkAbout16-170� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 5 2240-1 82 6 Q 19) 356-5040 1319)356-5497 FAX 1. Name (REQUIRED) . 2. Address (REQUIRED) IDENTIFICATION NO. l (Q' I -I O (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 First N vl q( / Middle /"- � _ /✓01c(Y Last A VI if lQ_J 3. Contact Information (REQUIRED) Email: I I - U Phone: (All written communication serffvia email) 4a. Driver's License expiration date (REQUIRED) V I I;Lq 12O b. Taxicab Business Name (REQUIRED) -10 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 o o. ? cn What happened to the charge? (Circle one) 0 Convicted Dismissed Deferred Suspended Plead Guilty- Other I� r 7. Have you been arrested/ charged with any traffic offenses in the last five years? �d 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? /✓ (7 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) ✓— o 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 that I have issued to me by the Iowa Department of Transportation a valid Driver's license number I p :5p 4 - issued on oi/ l3 expiring on p�2 ci 12o -2A I understand that if I falsely answer'any questions In t is an pplication, 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, Cha ter 2 f the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date ti 1`13 i STATE OF IOWA COUNTY OF JOHNSON Subscribed nd worn t99 before � .tP r7.77M me by �rI Y�Q S f Vv r1AAe-C—L on this Q ' day of in and for the 13tate of Iowa 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 offAcWa City (Title 5, Chapter 2, City Code). of f Xiver's license 1 [ Z(/ 2 or Dat 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. Signa of City Clerk or designee 6r/� /lo Dare aa+aa++a+aaaa+aaaaaaaa+aaa++++a+++++++aa+aa»+:»:aaaattaa:aaaaaa:aa:+aa+aa:++raa+aa+ar+araama+aaaa+++raaaa+a+as++a++aaa++aa++a+eaa+aia+++aaaa Office Use Only Approved application DCI report State certified driving record Website update CIe,W MIDRN ADGE PPUK14amen WDOC 0712016 FrAug_23. 2."6j: 1.rlDiv of Criminal—Investigation oa/1a/2O7813:4No. 1264B3.P...1/2,/ooa STATE E QTY ROW Request Foral' ,u5r TO: Iowa Division of Criminal luvestigation Support Operations Bureau, 1" Floor 215 E. 7°' Street DesMoiuea,Iowa 50.319 (514) 725.6066 (515) 925.6030 Fax t I•�1 v� e Date 0 Zh���(t�_ on: 1411(45 DCI Account Number: Iky-) ;I "1~ (ifapplitable) From: City 0f Iowa City City Clerk's office 410 t. Washiu„ton Sireat Iowa City, IA 32240 Phalle: 319-356.5041 Fax; 319_35556-5497 /4 H _ /J ca u Y'' �i\iale ©kelnale lvatver 12Jormafionr Without a signed waiver ilrom thesubject of the request, a complete crltninal history record may not be releasable, per Code of lows, Chapter 692.2. )Par comolet0 criminal history record information, as allowed by taw, always ablalln a Watvaraionaturo. G'nm tho, en6inet nf&& %---e Waiver Release: Ihcreby give permission for Ole abovo rtgaestlng official to emsduct an Inca criminal history record dteak wiut thcDivision of Criminal Inwestigalion (DCI). Any criminal history data concerning me [lint is maialained by the 1 n�sy be relcmd as allowed by law. Waiver Signafttre; �'�” Iowa Criminal Hisfory Record Check D --ii s As of k � , a search of the provided naille and date of birth revealed; No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attacbed, DCI DCI initials DCI -77 (08125110) Received Time Aug. 18. 2016 1:21PM No -2085 (DCI use only) try em ui C410WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN wwwowadOt.goV Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-9124 1800-532-1121 -532-1121 1 Fax: 515-239-1837 www.iowadot.gov Inquiry Date: 8/18/2016 Customer #: 6508866 Name: Ahmed, Annas Mobarak Mohammed Nour Address: 2470 LAKESIDE DR APT 2 Certified Abstract of Driving Record DL/ID #: 108AM9795 (IA) Class: D Audit #: 1149536 Issue Date: 07/13/2016 Expiration Date: 01/25/2021 City/State: IOWA CITY, IA 522406746 Endorsements: 3 Mailing 2470 LAKESIDE DR APT 2 Restrictions: NONE Address: Restriction None Mailing IOWA CITY, IA 522406746 Supplement: City/State: Date of Birth: 1/25/1975 Sex: M History Information CLEAR DRIVING RECORD Name: Ahmed, Annas Mobarak Mohammed Nour DL/ID: 108AM9795 CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: c i�v�(! �j�f'�'`d'"` oeia f�( CDL Permit None Endorsements: Office of Driver Services CDL Permit None Restrictions: Iowa Department of Transportation ID Status: None DL Status: VAL CDL Status: None CDL Permit Status: ELG 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: >.•"""•:;`/ �4 8/18/2016 IOWA ' �'', D. O. T. c i�v�(! �j�f'�'`d'"` oeia f�( c1.Z 7f'••••"g� Office of Driver Services Iowa Department of Transportation Name: Ahmed, Annas Mobarak Mohammed Nour DL/ID: 108AM9795