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HomeMy WebLinkAbout16-187r IDENTIFICATION NO.Iff)� 1 (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 - (319) 3S6-5497 FAX First Middle Last 1. Name (REQUIRED) 44,41SAR / al6L-6/nl AK/1F_LI/ A2-IC4 2. Address (REQUIRED) Jidd. I ST Ad/k Ole C f- ( 104JC, S7- Z O 3. Contact Information (REQUIRED) Email: M({�1G1 Q�z ICS 6; MA le _ feu Cell Phone: 70.7_ 7- 77� Z- /} (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) 1 1 ( 0 ( / 20 1,;? - b. Taxicab Business Name (REQUIRED) (nla j_�T r 5. Prior experience in transportation of passengers: :14kj dirt vr�l 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? &Z 0 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? 41 n 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? Al d Type of offense Where W heno >`- m 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please i r ie IN naa (s) M DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CER i IED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF VIEW 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 N 3 F v issued on (lxpiring on f t� zo / I understand that if falsely answer any questions in this application, that this application may be denied. I agree that in making this application, 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 5Xl;iapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date 01 Z 6 STATE OF IOWA ) COUNTY OF JOHNSON ) {� n scrib d an sworn to before me by Ra_ sar`�- f�)�DLte,IC' L Z-4 on this 2 day of 1io 1,o„ a_a r J..n4f'ci,r-. 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 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. Signa re of City Clerk or desig ee -?/a /i; Date 1Mf######'#fi#1411!!1!##4f1M1H111f111!#111#Yf#f#flf1H######Hf#1-##'######1411 f fNfff11f1f111fNfH111f1111111f111111f11f ff1f111flf1ffff#Yf1f1f Office Use Only Approved application DCI report State certified driving record Website update aervrrnx1DRNMAMEAWL92014en aee DDC 07/2016 N d c� cnCn �� rn M rn a M _ aervrrnx1DRNMAMEAWL92014en aee DDC 07/2016 Sep. 2. 2016 10:46AM Div of Criminal Investigation No.2191 P. 1 From:Clty o/ law& C11y Clerk Clrlac 3163 3566667 08/31/2016 13;31 8666 P.002/002 r STATE ®1F IOWA (Cidnbinal Hiaoiry Rec®rrd Checks Request, Form To: Iowa Division of Criminal Investigation Support Operations Bureau, l° Floor 215 E. 7u' Streat Des Motnes, Iowa 50319 (5I5)725-6066 (515)715-6080 Fax I am reauestine an Iowa Criminal Histary Record Clreek on: DCI Account Number: _ (if applicable) -_----- From: Citv of Iowa Clly _ City Cierk's Office 410 E. Washington Street Iowa City, IA 52240 Phone: 319-356-5041 Far: 319-356.5497 Last Name (mandatory) First I1IAMC mandatory) Middle Name (recunumendcd) _ 6dzl<A�l� G�R.lsarti Ntol7(e.(cPt , Date of Birth (nrandawy) Gender (mandatory) Social Security Number (recommended) . o 19 Z Male ❑Female h ql 3- o ff-5-,( 6 q Waiver Injormaafion: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always Main a waiver signature from the subject of the request, Waiver Release: I btreby give permission for the above icqucsting ohicial to conduct an lova uiminal history record eheels 1vid1 the Division ofCaiminal Invastigelion(DCi), Any uiminal history delaconeemingmethatismaintainedbytheDClmaybereleasedasallowedbylaw, Waiver Signature:---------�j Iowa Criminal History Record Cheep Results ;—: roto�nscanl�=— As of _ y''' b , a search of the provided name and date of birth revealed: Cur, ye� No Iowa Criminal history Record found with DCI L © Iowa Criminal History Record attached, DCI # �• ' N DCI initials__-_ DCI -77 (08/25/10) Received Time Auf.31, 2016 1:15PM No.3036 Iowa Department 01ke d MW Services M Sax 9204, Oen Marren, to W306,=4 of Transportation (Tall Free) 8DO.532-1121 51&244$124 FAX: 51&239.1837 Convictions Citation Date Certified Abstract of Driving Record ACD Inquiry Date: 8/31/2016 DL/ID #: 473AF1848(IA) Customer #: 5761443 Name: Abdelrazig, Maisara Class: D ID Status: None Address: 1853 HOLLYWOOD Audit #: 9635912 DL Status: VAL CT Issue Date: 12/11/2015 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 11/01/2017 CDL Cert Status: None 522405931 Endorsements: 3 CDL Med Status: None Mailing Address: 1853 HOLLYWOOD Restrictions: NONE Restriction None CT Supplement: Date of Birth: 11/1/1972 Mailing IOWA CITY, IA Sex: M City/State: 522405931 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 03/22/2013 05/06/2013 592 Speed ISpeed W1 05108/2016 07/18/2016 S92 IL Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date I Case Number JUR 11 15 2014 827434 IA Name: Abdelrazig, Maisara DL/ID: 473AF1848 N Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department Aransportation, do hereby certify that I am the custodian of the records held by the Office of Driver Services, that this 1i ii R e accuril copy of an official record currently in the custody of said Office, and that I have been authorized by the Dirdct6rJif thg Iowa'=3rtment of Transportation to so certify. c..1 N Y�}'t <m -9 1 •, In witness whereof, I have caused my signature and the seal of the Department to be set upon this documeAf; at Ankeny, Iowa this date: r), Name: Abdelrazig, Maisara DL/ID: 473AF1848 Anw Office of Driver Services Iowa Department of Transporation N O C) C ---M " C/) _ _ til70 N