HomeMy WebLinkAbout16-226� r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO.
(�- -'GG(q
(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
Middle
19-vx
W CA
Last
2-1
3. Contact Information (REQUIRED) Email: K4pyho,v P� �1r } ntai� G n "A Cell Phone: 3'19 - -3 9 3- 5- i I
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(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) 0'1 /I (�, /2,:7( R
b. Taxicab Business Name (REQUIRED) c" +i ) C o b
5. Prior experience in transportation of passengers: /Vo b r i (p a ti u j e1; ✓ --� /id L. ro v, s
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AmI Ml(�I(sv f '�Y'ti�ns �Ju/��nT+— .r YY ✓4r n .� Avr+tr�G..v� 't'<<�s L�r� _
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? IVO
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? 5.e* --t 4
Type of_Ioffense
(Where C/Whe�ny
-3005 o/ o,; -
What
s
What happened to the charge? (Circle one)
Convicted Dismissed
Deferred Suspended Plead GSiil Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _ N 0
c.�
Type of offense Where C-3
—IC`1 J
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pwal le thda
MID n'
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)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify Ilh t1 [have issued to me by the Iowa epartment of Transportation a valid Driver's license number
� 3�`S �{ �5 7 �issued on O1/l-4-12cl3expiring ony9/(Q 12,ojq . 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date / O -
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by K o, p. o.) c VIA , A Si - c, on this 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 Driver's license D'%• /s • 2-0/ 8
Signature of PolicA Chief or designee
•07.Zd6
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.
n sure of Cify Clerk or designee
Approved application
DCI report
State certified driving record
Website update
Date
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TATE OF IOWA
`ter 1 7
RequeaForm-
.rlYAw,
To: Iowa Divisi0r, of Criminal Investigation
Support Operations Iluroaa, I't Floor
215 Z 7'a Street
Dart A9atnes, Towa 50319
(515) 725.6066
(515)725-6000 Fax
On
Last Name (mmYama y>
Yate of Birth (tnanaatory)
o9_ig �9s
91"It Nalne (mer
)<'-e-A YAR It
UCI Account hrumber; q0 6'2 - r
--(ifnpptisshrr.) ..—
From; C4 i^tv of Iowa City
City Clerk's office Y
410 E. Washington gh_cet_—^
lows City, IA .52240
Phone! 319-356.5041
parr 379-356-5497 ——
fiddle Name rrau
6�Ld ("e V�
ZMale ®female I v� � ' 62 — T6 - 'V /
WON? [nf0rn10tiO4,' Without a signed waiver from the subject of the request, a complete et•imfnel history record may not
be releasable, per Code of 7ovs'a, Chapter 692.2. Tor complete criminal history record to formation, as allowed by law, ahvays
obtain a walver signature from the sub t act of the rennest_
Waiver)elea$C: I hereby give pcmaissiml for rhe above requcilirvy a>rcial to conduct on Iowa criminal history record check with the Diviiion ofCtimiiul
Invrnigotion (DCI)• any criminat h$tor)•dala eoneernI I
V me that ii manvainetl by rhe DCl may be released as ollow'ed hylaw.
Waiver Signature:
YO` -12 Criminal History Record Check results
met pia Drays
As of 1 C�a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record altached, DCI #
•1
,
DClinitials 4L ;. w
-z T^DCI-77 (08/25/10)~
Received Time Oct, 3, 2016 3:36PM Ro,5281
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SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'(OWadOt.gOV
Inquiry
Date:
Customer
Name:
10/4/2016
6142527
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1 800-532-1121 1 Fax: 515-239-1837
www.iowadol_gov
Certified Abstract of Driving Record
DL/ID #: 733AJ9154 (IA) CDL Permit Class: None
Class: D
Mustafa, Kamall Eldlen Audit #: 7349572
Address: 2602 BARTELT RD APT Issue Date: 09/17/2013
1C
City/State: IOWA CITY, IA
Convictions
Expiration 09/18/2018
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
522462727
Mailing
2602 BARTELT RD APT
Address:
1C
Mailing
IOWA CIN, IA
City/State:
522462727
Date of
9/18/1975
Birth:
None
Sex:
M
Convictions
Expiration 09/18/2018
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
10/05/2014
CDL Cert Status:
None
Speed
CDL Med Status:
None
History Information
Citation Date
Conviction Date
ACD
Explanation
County
JUR
05/23/2014
09/04/2014
S92
Speed
Johnson
,IA
10/05/2014
10/16/2014
S92
Speed
,Johnson
IA
Name: Mustafa, Kamall Eldien DL/ID: 733AJ9154
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:
IOWA 10/4/2016 L2
d0 e O
o,
D. 0. T.; ,Q,lta�..fl
9f DBIYE9g Office of Driver Services