HomeMy WebLinkAbout16-192CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa S2240-1826
(319)356.5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO.,
(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 appUealron
First
E
Middle
3. Contact Information (REQUIRED) Email: am,n-uOCuhc27o�`/mdrL-towCellPhone: �5-/5"77ID666
(AII written communication sent via email)
4a. Chauffeurs License expiration date (REQU
b. Taxicab Business Name (REQUIRED) _Ci
5. Prior experience in transportation of passengers: , S / n C- I q
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State
Type of offense
y'
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
Have you been arrested / charged with any traffic offenses in the last five years?
� r
i r...
N ,
Other %1D
Type of offense Where When
2 Pelt j�v I K COu +� Zai ole(/g
�P-pP<r S IA oy /2e
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked In the last five years?
Where
a
When
/cf
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please provide the name(s)
IVa
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)
02015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb certify that I have issued to me by the Iowa Department of Transportation avalid Chauffeurs license number
`�I ouFi! Issued on oS7o7/ly expiring on ��!/05/!56 I understand that if. I agree that in making this application, I
falsely answer any questions in this application, that this application may be denied
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 Date 0 y / - G
lfi;fifilli...i3333iAftMff'it3433331t3i33Mfift;34}Nfitiii'tY33tttff RYi;333;iiit}yiiiif31133#yi#�.ilii;YARi3;RfFARiifiiiit}py3M3t3333334N333 RMiA
STATE OF IOWA )
COUNTYOFJOHNSON I
Subscribed and swym to before me by AyA; ,1 . 26r )dr-a�x;im on this 2-1 day of
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 Chauffeur's license (5r 2iJ(
12-f
Slgns�oyolice Chief or designee . Dale
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.
Sigriatftfft of City Ulefk or designee
Date
v - - � �n..«���m,.�f1f3f3y 33333y3iN3l31iX3,r13HlfiM1ii
^l
C1
Office Use Only
Approved application r r\)
Fay
DCI report
State certified driving record
Website update
N
n
Cie, AXIDRrvanncenvmO2014 o,dld.00c
031'2015
DOT vwAr iowadot.gov
SMARTER I `_iMFL_F I CUS'E)" EF DRIVEN- -- ---_ =-.1.F ...�.
DRIVEN.-- Office of Driver Services
PO Dox 4204 Des Moines. IA 60366-92134
Pho^ 515 _44.9124 1 ECD -5-32-1'21 1 Fax: 515-2394837
www1owadol.gov
Certified Abstract of Driving Record
Inquiry Date:
9/29/2015
OL/ID 0:
673A]0477 (IA)
CDL Permit Class:
None
Customer S:
6068081
Class:
D
CDL Permit Issue
None
09/20/2015
09/24/2015
S92
Speed
Date:
IA
Name:
Ibrahim, Amin Mohamed
Audit #-.
9066622
CDL Permit
None
Adam
Expiration Date:
Address:
2420 BARTELT RD APT 2C
Issue Data:
05/07/2015
CDL Permit
None
Endorsements:
Expiration Date:
04/05/2018
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462707
Endorsements:
3
ID Status:
None
Mailing
2420 9ARTELT RD APT 2C
Restrictions:
NONE
OL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462707
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
4/5/1968
CDL Cert Status:
None
CDL Med Status:
None
Sex:
M
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanetlon
County
JUR
06/18/2014
07/07/2014
S92
Speed (10 mph & under In 35-55 mph zone)
Palk
IA
09/20/2015
09/24/2015
S92
Speed
Johnson
IA
Name: Ibrahim, Amin Mohamed Adam DL/ID: 673AJ0477
Pursuant to Iowa Code 5321.10, I, Kim Snook, 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:
IOWA
).0.T.
Name: Ibrahim, Amin Mohamed Adam DL/ID: 673A70477
9/29/2D15
office of Driver Services
Iowa Department of Transportatl ^;'
�i
;.
11[
State of Iowa
Division of Criminal Investigation
215 G.7" Street
Des Moines, Iowa 50319
Phone: 5151725-6066 Fax: 515!725-6080
Iowa Criminal History Record Check
Walk -In Request
Your name e ' rn
Address: 2.G
City/State/Zip: :50Wq iA 2W&
Phone #• j o
Requesting am Iowa criminal history record check on:
Fill in all shaded areas.
Last Name ,tpellnto (mandalcry)
First Name Prrmer,N'nmb" (mandatory)
Middle Name Segundo A'mnbre (recommended)
f b r -a �X k Nr ^
P�1� n
iu 0 Kr_tYqvj AackVA
Date of Birth Foch,?&rwenru (mandatory)
Gender cenere (mandatory)
Social Security Number krecnmmo&d)
Q ql O,S l 1949
,Male ❑ Female
3 Z-/3 2
Waiver Signature Ftnm or the request k on yourselL please sign It the request ie on x mwue elst, mite N/A )
DCl USE ONLY
Results
Asof l -15 a name and date orbirth check revealed:
G
record foundn
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7�No
vj- -1 ��
F1Record attached DO #
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DCI initials (W
Qx
z�
F- _
Receipt
Number of requests j x $15.00 per last name = Total amount
Method of payment: �_ cash money order check # MasterCard or Visa
(Inst 4 digits)
Cardholder's name a?
�r Ut
DCI initials J» n
t
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Credit Card # Exp. Date
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DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)