HomeMy WebLinkAbout16-174I
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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 3S6-SO40
(319)3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO.
I �- OLA
(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: & iw-01 V05m ;(• QY" Cell Phone:
(All written communication sent via email)
4a. Driver's License expiration date (REQI
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
N
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or else�Aere?':ji3
Type of offense Where � ten wo �—
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? 10
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? �O
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)
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 her?y rt'��ffyy that have issued to me by the Iowa D pa men of Transport i a valid Driver's license number
�2 ;( \hamt issued on expiring on �(JQ I understand that if I
fa s� ely answer any questions in this application, that this app ication may be denied. jjI agr a 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 ApplicantDate U� a
ca
G
STATE OF IOWA 1 `
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Ale t",e X A- _ � L.fir, f � on this day of
A8 r� f
t J-1301�. C" _ S
WEA S.
MAYER Notary Public in d for the State of I a�—
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).
ExpiratiotateDeer's license /
Signa re of Po ce designee IYate
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.
Sig re of City Clerk or designee
DaA
1HlfHHIHIfHf!-1flHf++fHf+llHlflflXllHHlf fffH+H++Hf+lf f f 1lHlH1H1HHHf+f++H+Hf+l+ffffHl11f111H11f fYH111+++1+++HHHHHIH
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Cle*/ MDRNBADGEAPPL92014am da DDC 0712016
Rug. i9. 1U16 2:26FM Uiv of Criminal Investigation
..._ -------
08/23/2016 ,2:6No. 176463BP..2/8 /oo�
37ATE11 IOWA
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�`Cldlffii"21 HistorY Record Checki't Request Form
To: lawn Division of Criminal Investigation
Support Operailons Bureau, 1" Floor
215 B. 7" Street
Des Moines, Iowa 50319
(515)725-6066
(515)725.6080 Fax
I alp reouestinp an Inwa. Criminal Krictnw nnnn.•a n,.,,.� ..,..
DCIAccouotNumber: Lf ti uZ-�
(ifapyliooble)
From: City of Iowa City
City ClerhB office
410 E. Washington Street
Iowa City, IA 52240
Phone: 319.356.5041
Tax: 319.356-5497
Last blame (mandsw
First Name (mandatory)
Middle Name (recommended)
Date of Birth (111211aatag9
Gender (mendalory)
Social SecurityNumbermm
I�'C' ale ❑Female
jraeoended)
O — 9� — I VO
Waiver lnformuliott: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasablo, per Code of Iowa, Chapter 692.2. For complete crhn)nal history record information, as allowed by law, always
Obtain a waiver • Signature from the subject of the request.
Waiver Release: l hereby give pemlission forthe above requudng official to conduct an Iowa criminal history« cord check with the Division orCriminal
investigarian(DCI). Any uiminat hisiorydata eonecming me im i ntai by the DCl may be released as allowed by law.
Waiver Signature:
iowa_Criminal History Record Check Results 7.(DC[UseAs o£ -?Ae -I,(7 , a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal T-listory Record attached, DCT 11 � _ _ � ', :•;
DCT initials M
.0
llUl-/ / (US/L)/lU)
Received Time Aug.23, 2016 12:39PM No.2418
C4Ji6iiiADOT
SMARTER I SIMPLERI WVVW.IOWadOt.gOV
CUSTOMER DRIVEN
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
www.lowadot.gov
Certified Abstract of Driving Record
Inquiry Date:
8/23/2016
DL/ID #:
732AJ6748 (IA)
CDL Permit Class:
None
Customer #:
6138609
Class:
D
CDL Permit Issue
None
Date:
Name:
Ismail, Ahmed Hassan
Audit #:
1066149
CDL Permit
None
Expiration Date:
Address:
86 ANISTON ST
Issue Date:
06/09/2016
CDL Permit
None
Endorsements:
Expiration Date:
11/02/2017
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522402216
Endorsements:
3
ID Status:
None
Mailing
86 ANISTON ST
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522402216
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
8/2/1970
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
4ccidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number IUR
02/16/2015 846134 IA
Name: Ismail, Ahmed Hassan DL/ID: 732A76748
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I ar
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 c
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:
...........�9 4r
8/23/2016
IOWA *°4�t•
D. 0. T.
;� efJ
f '••••"•$�
Office of Driver Services
'a......
Iowa Department of Transportation
Name: Ismail, Ahmed Hassan DL/ID: 732A16748