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HomeMy WebLinkAbout16-2374a. Driver's License expiration date (REQ1 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pE 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A crA Type of offense Where When W hat happened to the charge? (Circle one) Convicted ismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? UV Type of offense What happened to the charge? (Circle one) Where 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? a 1 Tvue of offense 9. Have you ever Where When - m to be an Iowa City taxi driver using a different name? If yes, please prouid'etheename(s)� DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFiIED 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 IDENTIFICATION NO. % (11— Z T 1 (Office Use Only) CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Wa5hinglon Slreel Iowa City, Iowa S2240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) ;,I 6%A jyi��r�in 2. Address (REQUIRED) 'SLS � /n���g 3. Contact Information (REQUIRED) Email: ►1rt.�cl i �s�\.1.leicArh�, (_ n. Cell Phone: ZI (Allwritten commun ca ion sent via email) 4a. Driver's License expiration date (REQ1 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pE 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A crA Type of offense Where When W hat happened to the charge? (Circle one) Convicted ismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? UV Type of offense What happened to the charge? (Circle one) Where 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? a 1 Tvue of offense 9. Have you ever Where When - m to be an Iowa City taxi driver using a different name? If yes, please prouid'etheename(s)� DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFiIED 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 I } 7 Jag �Q )c( issued on g 1 _ J2 expiring on o I& - W - / t 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 furtr 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 of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date 10 — 2-C,1 11fffHfl4}fHf44##!!4!H#H#H1ff1H11111HflHIfH}IHHH##YflfYMlflHlfHfHH1Hf11fi!*#H4#Y##YYH!*flYflHH1H*HHffHfHHlf}H!*Yf1'f STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by f\. "Yy,,-icb, on this 20 day of Oc3nlvaf 2-n-7. 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 9C ��—�/) z Signature of Police Chief ordesignee 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. SignNwe of City Clerk or designee � Z�/4G to HlHY*HYf f:f rifHrrHHIHHH}H#+#H#HHIHHHYHYHrHf f rlHHrrHHIHrHrIH++.H#*rff f+fffff+ffif+YHHffYr�rHirrHIHrHHrHHlrelf c-� Office Use Only - Approved application ==.c', DCI report State certified driving record Website update v Clerk/rA%IDRIVBADGEAPPL92014amende .DOC 0712016 0c t. 19. 2016 2: 36 PM Div of Criminal Investigation No 5141 P. 1/2 Fro m:Cf[y Of law- CRY Clerk 0/1100 316 3666697 10/17/201E 11:02 11710 r.vue/002 STATE OF IOWA Criminal hiisEory Record Check o, yyJ Request Form ` I am requesting oil Iowa Criminal History Record Check on, Last Name (mandatory) Mrst Name (mandatory) Middlo Name tremm funded) 4Ik]u°imelciin Mo/j,�tiw-e� of 0 S — G tt _ 1 % � I E29ale OFemale I `i 91 -3S — `�o—?.S Weriver lnJOrmalfon. Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code orlowa, Chapter 692.2. For complete criminal history record information, as allowed by lam-, always obtain a waiver signature from the subject of the request, WelVeP Aefe(Ve: I hereby give permission for the above request'official to conduct en Iowa crhninsl history record rt,aek will) the division of Criminal lovesliption (DC). Any criminal history data concerning nm that is ma , ined by the UCI may be released as allowed by law. Waiver Signstifare: Iowa Criminal History Record Check Results As of__ Q ice, a search of the provided name and date of birch revealed: 9 No Iowa Criminal History Record found with DCJ ❑ Iowa Criminal ldistory Record attached, DCI DCI hritlals DCI -77 (08/25/10) PerrivPd Timr Orf. 9 9616 10.44AM N0.6910 UCI Account Number: qf�O3 - To: lavas Division orCi-lo incl Investigation From. _ G of lows CtfS, Support Operafimis Eiureau, I61 Flour City Clerk's off -Ice 215 L. 70' Street41011. Washinatou $tree( Des hloilles, Iowa 50319 (515) 725-6066 Iowa city, IA 52240 — (515) 725-6090 Fax --- — ___.�—•- 1 hone: 319-356-5041 Fax: 319-356-5497 — — I am requesting oil Iowa Criminal History Record Check on, Last Name (mandatory) Mrst Name (mandatory) Middlo Name tremm funded) 4Ik]u°imelciin Mo/j,�tiw-e� of 0 S — G tt _ 1 % � I E29ale OFemale I `i 91 -3S — `�o—?.S Weriver lnJOrmalfon. Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code orlowa, Chapter 692.2. For complete criminal history record information, as allowed by lam-, always obtain a waiver signature from the subject of the request, WelVeP Aefe(Ve: I hereby give permission for the above request'official to conduct en Iowa crhninsl history record rt,aek will) the division of Criminal lovesliption (DC). Any criminal history data concerning nm that is ma , ined by the UCI may be released as allowed by law. Waiver Signstifare: Iowa Criminal History Record Check Results As of__ Q ice, a search of the provided name and date of birch revealed: 9 No Iowa Criminal History Record found with DCJ ❑ Iowa Criminal ldistory Record attached, DCI DCI hritlals DCI -77 (08/25/10) PerrivPd Timr Orf. 9 9616 10.44AM N0.6910 f"e'luWADOT SMARTER I SIMPLER I CUSTOMER DRIVEN VVWW'Imidot SOV 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.iowadot.gov Inquiry 10/19/2016 Date: Restriction None Customer 4102089 Endorsements: CDL Permit Name: Salih, Nagmeldin Restrictions: Mohamed Address: 2548 INDIGO DR City/State: IOWA CIN, IA 522406808 Mailing 2548 INDIGO DR Address: Mailing IOWA CITY, IA City/State: 522406808 Date of 8/4/1967 Birth: Sex: M Convictions Certified Abstract of Driving Record DL/ID #: 137880959 (IA) CDL Permit Class: None Class: D Audit #: 6175614 Issue Date: 08/01/2012 Expiration 08/04/2017 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: ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County JUR 07/18/2014 07/25/2014 'S93 ..Speed Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 07/18/2014 1,808533 IA . Name: Salih, Nagmeldin Mohamed DL/ID: 137880959 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 a`lidraccurate copy of an official record currently in the custody of said office, and that I have been authorized by the Director of the Ioga Department of Transportation to so certify. - -._A ^ In witness whereof, I have caused my signature and the seal of the Department to be set upon this-dotument, at Ankeny, Iowa this date: =-�VFNICIf p� �p Name: Salih, Nagmeldin Mohamed DL/ID: 137880959 10/19/2016 Office of Driver Services Iowa Department of Transportation N f:a C:) N © d X fv