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HomeMy WebLinkAbout16-18874r'lll2vJEp��� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa S2240-1826 (3 19) 356-5040 (3 19) 3S6-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. �( �e — j (Office use v, ,yj 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: L1 ,4g6a&47 ICS�A,(A/( e_ j1 Cell Phone: X52 (All written communica ion sent t via entail) 4a. Driver's License expiration date (REQUIRED) ( o (, 20 / -*- b. Taxicab Business Name (REQUIRED) _ / C-47EY cc, Lj . 5. Prior experience in transportation of passengers: Zrr rF O(rt tr I - (a t , A 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 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? Al 0 Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your drivel's license or chauffeurs license been suspended or revoked in the last five years? A/ r7 Type of offense Where Wheno 0 0 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pre t l name /t%d DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CER— IED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE Cl RVIEW 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::� SA F 15y S issued on /2�( t l I LF- expiring on f i/ i( z o 1'd— . 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 Titje 5APapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant ( Date0l — 6 STATE OF IOWA ) COUNTY OF JOHNSON ) scrib d and sworn to before me by K6L Sct_r,--- &6adelt"LL 7-t' on this 2 day of Notary Publi in and for the a of Iowa commission Numtier2218,9 M Comm E Yes #4#t4/t*####4#;##}####t ow 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 Cil % 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. ?Zes,� _W .uJ Signa re of City Clerk or desig ee Date ff4f4#fY#ii4#fff}fltt#iit#i!!i}tttlttf*fifff#YY##ffllYfe#i#4fMl,!##4#i#fiffY*##flMlfffli##fff4fltHiflff!!}###ffi}fiiitff!!Ni#iiifRlYi#iffflM}f Office Use Only Approved application DCI report State certified driving record Website update aP,wrAwDervanoceAPPL92014a ded.Doc 07/2016 N O c7 `r rNTI �+ C > --1 -a G i --1 n N Fri aP,wrAwDervanoceAPPL92014a ded.Doc 07/2016 Sep. 2..2016 10:46AM Div of Criminal Investigation No. 2191 P. 1 FrOm:Cley of IOW& City Clerk C,M.. 31® 35G6.97 O6/3112016 73;31 OGGO P'002/0412 STATt E O F IfO S'A (9� Crdnbftmal Hfgtorry Il�ecovcll Check ) Re oust Foam' To: Iowa Division of Criminal Investigation Support Operations Bureau, I" Floor 215 E. 7a' Streat I)esmotnes,Iowa 50319 (SIS)725-6066 (515)725.6080 Fox T Alli r9mieatina An tnuo. Or;minal ra;cenn, RnenrA ri,nnL nn. DCI Account Number: From: Cite of Iowa Clty City Ciertc's Office 410 C. Washington 5(•eet Iowa City, IA 52240 Phone; 319-356-$041 Fax: 319.356.5497 Last Name (mandatory) First Naive mandatory) Middle Nalne (reroamlendco) Date of Birth (mandatory) Gender mandatory) Social Security Number (woonnenaaa) \ 1 J o t( Z Male ❑Female 6 q.? - r) --�-- 5-Y 6 of r% r'afverl'nformaUOJ Without a signed waiver from time 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 obtain a waiver slgnalure from the rubiect of rite request. I' iVerReleaSe: I herebygivepermission rorlhe above requesting official to conductan townctiminal historyretardthecllnidi the Division of Criminal Investigation PCT). Any Liminal history gala eoneereing vie that is Inainained by Iho DCI may be released a9 allowed bylaw, Waiver Signature; / Iowa Criminal History Record Check Results ^ e>" troorneaanlyj•� As of pI''Z k� , a search of the provided name and date of birth revealed: 6�y No Iowa L-Iminal Histol)' Record found with ICI (71.: © Iowa Crjnrinal History Record attached, I)CI # - W 00 DCI inilials�_ DCI -77 (OMS/10) Received Time Aut,31 2016 MUM No.3036 Iowa Department of Transportation Ott of Driver Semi= (roll Free) ODO-532-1121 P4 Box 92M, Des Mmes, [A 50315.9204 515-244-9124 FAX ai 5 239-1837 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 IUR 03/22/2013 05/06/2013 S92 Speed WI 05/08/2016 07118/2016 S92 Speed IL Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date I Case Number IUR 111115/2014 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 o�fransportation, do hereby certify that I am the custodian of the records held by the Office of Driver Services, that this iseatttue accu—r—Atj copy of an official record currently in the custody of said Office, and that I have been authorized by the DireoFf thg Iowa partment of Transportation to so certify. -in 11 - i r c7 M 77) rn i In witness whereof, I have caused my signature and the seal of the Department to be set upon this documea, at Ankeny, Iowa N this date: L 'F _IOWI�: D 0, T. q� Office of Driver Services Iowa Department of Transporation Name: Abdelrazig, Maisara DL/ID: 473AF1846 N O n N