HomeMy WebLinkAbout16-223CITY OF IOWA CITY
410 Ea5l Washington St reel
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
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 application
First Middle L
1. Name (REQUIRED) r5MP0,L I F(h"-t C'c
2. Address (REQUIRED)
3. Contact Information (REQUIRED) Email0m o y ELI,l 436DY4(,. -I n Cell Phone:
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) /O 0 ? I
b. Taxicab Business Name (REQUIRED) C ; t���
5. Prior experience in transportation of passengers -
6.
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?A�
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?
Type of offense Where When
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That happened
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to the charge? (Circle one)
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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?
Type of offense
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(sl ,r/�
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED !f
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
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
�Yf�� �} ( n / issued on n5/r7�expiring on �. 1 understand that if I
falsely answe' er any questions in this s application, that this applic ion 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 aiy Saw Date / Z-o��j
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ILA -P _ 5 it on this _7�9 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).
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at
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.
Signa1are of City Clerk or designee
Office Use Only
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Approved application
DCI report o
State certified driving recordo71
Website update
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Clerk)TMIDRivenocEAPa.92014eme�ded.Doc 07/2016
"> 09/27/2016 12:1. 69 e, r.0 02/002
STATE OF 10WA
Clrimillaf History Record (Chevit
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'fo: ]area Division of Crinrtnal Investigation
Support Opel'atlols Durcau, Is' Floor
215 t?, 71, Street
Des htohnes, Iowa 50319
(S] 5) 725-6066
(51.5) 725-6060 Fax
an Iowa
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DCI Account \huuber: _ 400 D� - t=
(ifappliteblc) ..
From: City Of Iowa Cit -
City CIer1Ps Office
_4101:, washin ran $trcet
Iowa Clty, [A 51240
Phone; 319-356-5041 4
Fax; 3!9-356-5497
IQ - I �tjjcj,equest
igned waiver fYom the subject of , a complete eriminal history record may not
be releasable, per Code ofton'a, Chapter G92.2, For co_ molete criminal history record information, as allowed by law, always
obtain a waiver si Lneture from the subleet of the reaueot.
Wigiver Release: I hereby give permission for dre above reque$ling orneiol to conduct ani Iowa erinsinal hfnory record check wilh We Division of Criminal
Imzsligatios (DCI), Any criminal hislory dale concerning me that is Mail Billed by the DCl may be released as allowed by lau•.
I'I/41ver S'{Priatu e:
(DCI use only)
As of C1 �,� (� a search of the provided Dame and date of birth revealed:
C3Fri�
' - i
No Iowa Criminal History Record found wish DCI F.I
Iowa Criminal History Record attached, DO
DO initials
DCI -77 (09/25/10) -- — -� —~— —
Received Time Sep.27, 2016 12:01PN No.4858
C410WADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWBCIOt.gOV
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837
www.lowadot.gov
Inquiry 9/29/2016
Date:
Customer #: 5868786
Name: Salah, Omer Elhaj
Certified Abstract of Driving Record
DL/ID #: 54SAGO871 (IA) CDL Permit Class: None
Class: D
Audit #: 1011345
Address: 1637 ABER AVE APT 2 Issue Date: 05/17/2016
City/State: IOWA CITY, IA
522464728
Mailing PO BOX 452
Address:
Mailing IOWA CITY, IA
City/State: 522440452
Date of 10/15/1967
Birth:
Sex: M
Convictions
Expiration 10/15/2021
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrictions:
IA
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
Speed
Status:
IA
_
07/09/2013
CDL Cert Status:
None
Speed
CDL Med Status:
None
History Information
Citation Date
Conviction Date
ACD
Explanation
County
JUR
)3/_03/2013
'.03/25/2013 _ _
S92
Speed
'Johnson
IA
_
07/09/2013
08/23/2013
IS92
Speed
Johnson
IA
_
11/21/2015
1.. 01/05/2016
MOS
Fail to Obey Officer
.Johnson
IA
Name: Salah, Omer Elhaj DL/ID: 545AGO871
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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:
Name: Salih, Omer Elhaj DL/ID: 54SAGO871
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9/29/2016
,
IOWA
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V DRIVE®
Office of Driver Services
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Iowa Department of Transportation
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Name: Salih, Omer Elhaj DL/ID: 54SAGO871