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HomeMy WebLinkAbout16-185CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 3S6-5497 FAX IDENTIFICATION NO. t. O -I 5S (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 Middle Last 1. Name (REQUIRED) MCP. vrl i Aakki G(aryi7N 2. Address (REQUIRED) _'?ZoAOritr>vt by Ibu//�C(T� -1A 922irG 3. Contact Information (REQUIRED) Email: H.A/pvn/✓1 /0 Aet-/yyr,/,C. Cell Phone:;, 2 32-1 /4 -ZZ (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) 13 . 201 f b. Taxicab Business Name (REQUIRED) 417&,c av1 7'19,r CA� 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? N O 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? NO Type of offense iN, Where When sveur rickti '� r o8•s) - 1; What happened to the charge? (Circle one) oZ •Zo _ I S Convicted Dismissed Deferred Suspended lead Guil 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 U� 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, pleasev,-9vidiighe nary s) n!o DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA't CERTIFld&7 DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHI�g REVe# You must apply for an individual Department of Criminal Investigation Report (form availaw,,upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APPLa (CATION 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 4-65 Ar7ng& issued on o4-,„,0.- i4 expiring on O9-/3_ ! . I understand that if I fa sely 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 � „ J Date Oi IT_ fflRR}R+#i#iiY##NHIfINIlRR+*}R}#++Y+#iN#i##i1!l NlRRlIRRRIRHHi}+H+N##441 lflf 4##NRIfIRRR*}R+###N###4f####4NN11llRII**YY+N+++###N#N STATE OF IOWA ) COUNTY OF JOHNSON ) Su scribed and sworn to before me by lkotier(,e.eO ii on this t day of lu Le ►� S.MAYER Notary Public 14anid for the State of wa Mr eon 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 Cij�owa City (Title 5, Chapter 2, City Code). license CI I � I (T designee q_H 0 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 re of City Clerk or designee y- -Ao/ Date N 1f 11HYff+141fYNNNNlfNNN1f 1HYf411fNYNNffN/Nffl1111//11111++#H#4NlNfNlNN4fHfflRYflflf fif#}ffllffffC9f4ff11f#Yff 111111 41NN1 Office Use Only og I Approved application DCI report State certified driving record Website update --i C') m terra --u �T N s-' N J aenrtnxiMMW)cen 92014a�.DGC 07/2016 Aug. 23. 2016 9:42AM Div of Criminal Investigation No. 1284 P. 2/2 Fr. _M-. -_- CI EII. _...__ -._ __.. _. Off /1B /2016 n3:n_ ..833 ...r/oo3 STATE Or, IOWA { ` cC✓rriiviin ual History Reetiyd Check Request Form TVVTr o To: lows Division of Criminal Investigation Support Operations Bureau, I" Floor 215 E. 7" Street Des Moines, Iowa 50319 (515)725-6066 (515)72S-6080 Fax I am requesting an Iowa FC a wl ('vi ©i- /3./�4 ez Recofd Check on: DCI Account Number; Jkx-),;t - F fir applicable) Prom: CitS' of Iowa City Clty Clerlt'a office��— 4101;. Washington Street Iowa City, IA 52140 Phone: 319-356.5041 Fa a: 319356-5497 First Name (maidalory) Gender (mandatory) 5MI-ale [IFelnale Name 215_ 5-5e?2 waiver/njorinarioar Without a signed waiver from the subject of the request, a complete criminal his(ory record may aot be releasable, per Code of Iowa, Chapter 692.2. ror complete criminal history record information, as allowed bylaw, always obtain a waiver sionahsra frnm tho nkGrt of MF .e.. —t WaiVer ReierrSg: 1 herebygive permission Par the above requesting official to randuci on Imva criminal l-h(cry record check v,itb the Di.dsimf of Criminal In vesfigotion (DCI). Any crimlnol history dila concurring no That is maillnlned by the DCI lnay bt rdtased es aheived by Ina. Waiver Signature; As of IN a3 `I' j , a search of the provided name and date of birth revealed No Iowa Criminal History Record fowid with DCT i CI Iowa Criminal History Record attached, DCI 4_ DCI Utials _ DCI -77 (06/25/10) Received Time Aug. 18• 2016 1:27PM No. 2085 (Dc[�# only) sa a, t qC)L. 72C n (4-7 cn UI ARTS Page 1 of 2 CZ10WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN VVWW'IOWadOt 90V Office of Driver Services PO Box 92041 Des Moines, tA 50306-9204 Phone: 515-244-9124 i 800.532-1121 i Fax: 515-239-1837 www.iowadat.gov Inquiry Date: Customer Name: Address: 9/1/2016 5751120 Certified Abstract of Driving Record DL/ID #: 465AF7080 (IA) CDL Permit Class: None Class: D Elamin, Mohamed Bakri Audit #: 7953132 Mohamed 920 BENTON DR Issue Date: 04/04/2014 City/State: IOWA CITY, IA Convictions Expiration 09/13/2017 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit 522465216 Mailing 920 BENTON DR Address: None Mailing IOWA CITY, IA City/State: 522465216 Date of 9/13/1962 Birth: None Sex: M Convictions Expiration 09/13/2017 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: LDL Permit CDL Permit None Restrictions: IA ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: LDL Permit ELG Speed Status: IA 08/31/2013 CDL Cert Status: None Speed CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County 3UR 04/03/2012 06/08/2012 S92 Speed Johnson IA 08/31/2013 04/30/2014 S92 Speed Johnson IA 11/20/2013 04/30/2014 S92 Speed Johnson IA 02/20/2015 03/27/2015 S92 Speed Johnson IA Name: Elamin, Mohamed Bakri Mohamed DL/ID: 465AF7080 N O Pursuant to Iowa Code 4321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa De*g ment 6FTransportation, do hereby certify that I am the custodian of the records held by the Office of Driver Services, that thisdESCue 4 accul7qcopy of an official record currently in the custody of said office, and that I have been authorized by the Diregw:a, theiowa D ent of Transportation to so certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon thrs4lWmeq§ at A Qy, Iowa this date: C7?9 =9 1""t J IOWA %w,; D. 0. T. 9/1/2016 http://172.29.254.55/drivers/reports/customerhistorylcertifieddrivingrecord.aspx 9/1/2016