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HomeMy WebLinkAbout16-193CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) . 2. Address (REQUIRED) 3. Contact Information IF IDENTIFICATION NO. 1 Lo— is (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 4a. Driver's License expiration date (REQUIRED) ,g/ o7 / )6 b. Taxicab Business Name (REQUIRED) _ Ayr ee '%Cp. 11,v i 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? Where What happened to the charge? (Circle one) When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where What happened to the charge? (Circle one) 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? Where 9. Have yqupver applied to be an Iowa City taxi driver using a different name? If yes, Wim., 0 C' o+ r= -71 -i � eTFgvide, 4�he name(6) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT EYCEWIFIE&D 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 13 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 q 6p OF- q/ 3 issued on o/I<expiring on I understand that if I falsely answer any questions in this application, that this application may be denied. I agree hat 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 Date y OZ ZIK STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by on this day of wENDY S. MAYFR Notary Public in and 9 r the State of Iowa MY Camoviii .,. - ... ....:... 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 v(` v� >I y ),!>v Signature of Police Chief or designee gqo� 4 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. Sig re of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update GerkaMIERNMDGEAPPL92014a.naetl.DOC 07/2016 e :cr rN C?� 1 f� GerkaMIERNMDGEAPPL92014a.naetl.DOC 07/2016 Mug. )V. 11/10 I;07nv1 u I v of t,r lml nal Inv e5t 19 l 1 0 n IN O. LY IL r. C/4 Peo M;GIxy or low& Clty Clerk Oerlce 319 3666497 06/24/2016 12;13 p643 P.003/002 STATE OF IOWA Criminal Histary Recoird Check Request Form r To: Iowa Division of Criminal Investigation Support Operations Bureau, I" Floor 215 E, 7"' Street Des Moines, Iowa 50319 (515) 725-6066 (515)725-6080 Fax I am reouestine an Iowa Criminal History Record Check on: I)CI Accoaut Number: Yy'D•Z'r__ (ifapplicable) From: City of Iowa City City Clerk's Office 410 E. Washington Street Iowa City, fA 52240 Phone: 319356-5041 _ Fax: 319-356-5497 Gast Name (mandatory) MrstlName TMiddle Name (rccannnodw) As o£ , a search of the provided name and date of birth revealed: l(mandaloq) I-) ka mM C-- Date bate of Birth (mandatory) Gender (ntandalory) Social SecurityNumber (recommended) f7 © ?2113 I � T�� Male ❑Temale 5" C S 7-1 l Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Codo of Iowa, Chapter 692.2. Far complete criminal history record laformatlon, as allowed by law, always obtain awalversignature from the subject of the re west, Waiver Release: I hereby give permission for she above requesting official to conduce m Iowa criminal historyrecord chcdl whh the Division df Criminal hwestigallon(OCI). Any criminal hislory dalawnceminggm-e�m_al is maintained by the DC1 may bo released as allowed by late. `"`I7 Waiver Signature; V cl-�%CI�yC.� Iowa Criminal Histol v (Record Check Results As o£ , a search of the provided name and date of birth revealed: —I• No Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, DCI H_ _ ,,• 6W T DCI initials DCI -77 (08/25/10) A l T' a. - nI An +n. nn nee al. +Anr C4iUWADOT www.iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVER Office of Driver Services PO Box 92D4 I Des Moines, IA 50306-9204 Phone: 515-244-9124 1 BOD -532-1121 I Fax 515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 8/24/2016 DL/ID #: 960ZZ4343 (IA) CDL Permit Class: None Customer #: 3342803 Class: D CDL Permit Issue None Iowa Department of Transportation Date: Name: Elgaali, Wail Mohammed Audit #: 8347972 CDL Permit None Expiration Date: Address: 2442 ASTER AVE Issue Date: 08/12/2014 CDL Permit None r� Endorsements: Expiration Date: 02/13/2022 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522406731 Endorsements: 3 ID Status: None Mailing 2442 ASTER AVE Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 522406731 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 2/13/1986 CDL Cert Status: None Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Elgaali, Wail Mohammed DL/ID: 960ZZ4343 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: Name: Elgaali, Wail Mohammed DL/ID: 960ZZ4343 +""•'•�`/y'4� 8/24/2016 IOWA 0. f' __ OHIO„ Office of Driver Services ^” Iowa Department of Transportation r�