HomeMy WebLinkAbout17-018IDENTIFICATION NO.
(Office se Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
First Middle ^^ iLast
1. Name (REQUIRED) C)Mctr ka,A , A6 Eck ES,
2. Address (REQUIRED) ?(,�(-) @ Rtw4e 1-hPA _� 2A to V4 CeG 3A 522-46
3. Contact Information (REQUIRED) Email: Cell Phone: (�lq)383-b93(
(All written communication sent via email)
4a. Driver's License expiration date (REQI.
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of pa
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? U
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead GuiltyOtherOther
7. Have you been arrested / charged with any traffic offenses in the last five years? /lei
Type of offense Where When
r%YiViM L✓r�r.r� I„rH^^1 ,� rw� ) O l..rh C i -� � � i�—�i Ic I�t
What happened to the charge? (Circle one)
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? " NO
Type of offense Where When,
-'
i
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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 that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
��G Chi' -,p ` 1 issued on 12, 12al(6expiring on /l I understand that if
falsely ariswer any questions in this application, that this application may be denied.agrel a that 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 Applican Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by !Xrts on this �N _ day of
1�t10 �� ,Ok-t. \1��
in and for the State of Iowa
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).
license
G V Z//
Date
designee
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.
Sia of City Clerk or design
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
-1
CWkrrAY DRIVBADGEAPPL9201U.nde .DOC 07/2016
''JIOWA DOT
SMARTER 15IMPLER I CUSTOMER DRIVEN WVVW'IOWBC�Ot.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.mwadot gov
Certified Abstract of Driving Record
Inquiry Date:
1/27/2017
Expiration Date:
DL/ID #:
947AL1383(IA)
Customer #:
6416805
Class:
D
Name:
Idris, Omar Adam Abdalla
Audit #:
1502121
Address:
2608 BARTELT
RD APT IS
Issue Date:
12/20/2016
ELG
CDL Cert Status:
None
Expiration Date:
08/16/2023
City/State:
IOWA CITY, IA
522462730
Endorsements:
3
Mailing
2608 BARTELT
RD APT 1B
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA
522462730
Supplement:
City/State:
Date of Birth:
8/16/1978
Sex:
M
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
OL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status:
None
CDL Med Status:
None
Citation Date Conviction Date ACD Explanation County JUR
11/10/2016 ',11/28/2016 N63 Driving Wrong Way on One Way Street Johnson IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
11/28/2016 954714 IA
Name: Idris, Omar Adam Abdalla DL/ID: 947AL1383
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: Idris, Omar Adam Abdalla DL/ID: 947AL1383
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1/27/2017
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Name: Idris, Omar Adam Abdalla DL/ID: 947AL1383
,dan.30, 1U11,,1Q:5/AMa1.r9iv of Criminal Investigation O12Y,2O17 16:,No.24130pEr. 1/1,/002
-Jan. 23. 2017 1:18PM Div of Criminal Invesligation No. 1961 P, 2/3
PYOM:OIay Of Inca Clly 016ik Oflleu 310 566Ka0Y 01/2012017 16:21 0 11Y P,002/002
STATE OF IOWA
Criminal History Record Cbeck
01.1
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Reqnest Fortin
'ro: town Dlvltfon Ofevitninal InvUdgallon
Supporl OP61-atiour Duran% PFloor
215 L, 7" Slreat
Des Moines, 10WR $0319
(515) 725.6066
(515)715-6010 rax TOAV ID
1 Ain ranuP.el ina an Tnum Cri,v,:...1141.1 ,., a��1.1 dL -L _
CCI Account Humber. _Ll ot)•Z--f~
(lfapeligble)
From; Ry Or
City CIe1•kUmce
410 E, Washinglun Street_
IOWa Cily, ,A 52240
WR
TA FON phoum 319-356-504)
e 319.3S6.5497
TH FORI'i�x'
Last Name raaadator
First Naha (mandate
Middle Name peeommmded
TD2is
ow►a�
,�pAm
Date Of Birth Olndab 1 _
Gonder mendvo
Social Seeuri Number (terammntdeq
491 16 a /'It -78
Morale oFensaie
% C�4^U, L-�• Jy
U-1aiver MfornlMlonr Without a signed waiver n•om the subject of the request, a complete criminal history record may not
be releasable, per Code ofl'oul1,Chapter 692.2.Per complete criminal hislagretard Information, arallowed bylaw, ahvays
obtain awaiver signature from the subject atthe Vaguest,
F)fafVer RdfBnre: I nere►y,lve permlrslon lar Ne eheve Iequalfnjomciel to wndnG en Iowa ertmllnl hlaafy feeofd eaeek Nitb ane Dlvirioa of a/lmblel
Iaredllplion(1001). Any Kindnal h4luly delaaonerminamelh3tis malnnlned by the Dgmyberefeesedat allowedby low.
WntverSignnffdre:#�— v �l
vv+u.naana aaaawa♦a�ea.Va urV1lGGK l\CJt[��la �� (0cl Ne only).
As of _ �'� , a search of the provided name and date of Willi revealed: "
W, No Iowa Criminal Histwy Record found Willi DC)
t...
❑ Iowa Cfitninal History Record attaoliod, DCI #
DCl initials
UG1-17 (I)IM/10)
Received Time ,len. 74 7417 1•110M Nn 1070
Received Time Jan,27. 2017 2:06PM No -2359