HomeMy WebLinkAbout16-268!1 ®4
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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 3S6-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. l (r- Z LYV
(Office Use Only)
APPLICATION FOR TAXICAB I 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
3. Contact Information (REQUIRED) Email: Q7N e - .a Cell Phone:
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) Q l /O //z o 2-
b.
b. Taxicab Business Name (REQUIRED) Co 6
5. Priorexperienceexperience in transportation of passengers: f f,2
ni 6 z;; C'd,•vr., svw GLv �//O L,/iC! /s .All.
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
When
Other
C�:)
When
Other " C:'
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /v U
Type of offense
Where
-r
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please _pfovovi
ldeAft narM)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED(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)
0
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
y8i�tl l j� c, issued on /2 0 ' expiring on oi/o/ 202?. I understand that if 1
falsely answer any questions in this application, that this application may be denied. I agree that in-Imaking 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 5Chapter 2, of�the
CiCity Code. (Needs to be signed in front of a Notary Public)
Signature of Applican.,/ _ � /F�' Date g/�O
STATE OF IOWA )
COUNTY OF JOHNSON )
Aubscribed and sworn to before me by NtUAaf 011-tIC._ on this 8 day of
QGe� 7,CVLe
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
Signature of Police Chief or designee
C
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.
7�
SignNure of City Clerk or designee
D to
aerk/rAXIDRR?BADGEAPPL92014sm ded.DDC 07/2016
Office Use Only ' "i
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=a c)
co
a
Approved application
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DCI report
rev,
-
State certified driving record
Co
Website update
�
aerk/rAXIDRR?BADGEAPPL92014sm ded.DDC 07/2016
C,J10WA00T
SMARTER I SIMPLER I CUSTOMER DRIVEN vvww•iowadotgov
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-92D4
Phone: 515-244-9124 18DO-532-1121 I Fax: 515-239-1837
www.iowadot gov
Inquiry 12/7/2016
Date:
Customer #: 6158288
Certified Abstract of Driving Record
DL/ID #: 748AJ4707 (IA) CDL Permit Class: None
Class:
Name: Omer, Mustafa Elhadi Audit #:
10
9614263
Address: 1311 SOUTHVIEW CIR Issue Date: 12/03/2015
Expiration 01/01/2023
History Information
CLEAR DRIVING RECORD
Name: Omer, Mustafa Elhadi DL/ID: 748A]4707
CDL Permit Issue None
Date:
CDL Permit
None
Date:
None
City/State:
CORALVILLE, IA
Endorsements:
3
CDL Permit
522411046
Restrictions:
Mailing
1311 SOUTHVIEW CIR
Restrictions:
NONE
Address:
Restriction
None
Mailing
CORALVILLE, IA
Supplement:
City/State:
522411046
Date of
1/1/1970
Birth:
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Omer, Mustafa Elhadi DL/ID: 748A]4707
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
Office of Driver Services
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
Office of Driver Services
CDL Cert Status:
None
CDL Med Status: None
Pursuant to Iowa Code 4321.10, 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: Omer, Mustafa Elhadi DL/ID: 748A]4707
D IOWA'
12/7/2016
4
D. O.T.
JCc�1
0•'• :�
"^"
�f OBIVt6; E
Office of Driver Services
Iowa Department of Transportation
Name: Omer, Mustafa Elhadi DL/ID: 748A]4707
Dec, 5, 2016 11:32AM Dlv of Criminal Investigation No.8661 P. 1/2
F, u,.•... -•.y , "W. ny cl"r vuioa arr anb On V/ 11/28/2016 17:07 40745 P.0021002
STATE OF IOWA ,
Criminal History Record Check
Request Form �• s�
l 1
To: Iowa llivlsion of Crbninal Investigation
Support Operattons Otiveau, 1" Floor
215 L 71" Street
Iles Moines, Iowa 50319
(515) 725-6066
(515)725-6090 Fox
I am reouestine an IOWA Criminal Hiafnry RPPned ChPclr rnv
f)(3 Account Number: It O O _)" P
^ (ifappliC41c)
From: City Of Iowa City'
City Clark's Offico
410 Z. Washington "reet
—Iowa City,. IA -12240
Phone: 319-356-5041
Fax: 319-951-5497
LASE Na�.m�se�(man�datory)
Firsst�Name (nsandatory')
Middle NNaarne (recomnlbldcd)
Date of Birth mandaoryc
Gend��er��(maadalory) _
Social SecurityNumber (luomincnded)
O t �6 r I (
L+d'i�I ale ®Female
S)62 - 310 — 3 (d 07
Waiver Information: Without a signed waiver from the subject of the request, a complete criminal histuq, record Inay not
be releasable, per Code of Iowa, Chapter 692.2. For eomplele criminal history record information, as allowed by law, always
obtain s waiver signature from the subject of the request.
1'f River Release: I hereby give perosission for nu above requetling official to conduct an Iowa criminal historytuord check with the Division of Criminal
Investigation (DCI), Any aiminal hislory data concerning me that is mainlnincel by the DCI may be released a; allowed bylaw.
Waiver Signature:
--- - $
Iowa Criminal history Record Check Results (DCllist only)
As of _- l l S �(�a search of the provided name and date of birth revealed:
No lowa Criminal History Record found with DC1 n '
�. �.
Iowa Criminal History Record attached, DCI #_ t
-
DCI initials-fc-�_ } '
DCI -77 (08/25/)0)
Received Time Noy -26. 2016 3;49PN No -6934