HomeMy WebLinkAbout17-024CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319( 356.5D40
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED;
IDENTIFICATION NO. 1-7 � C70
(("ice use uizq,
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
3. Contact Information (REQUIRED) Email:Jocvtk n #-G, V Co-, )) Cell Ptio6:3I
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
I .+��� .� t•SK
b. Taxicab Business Name (REQUIRED) c -U ✓1 1- lif V S 7 a \ �OLD�t
5. Prior experience in transportation of passengers: 07S yPMes 9
6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere?.
Typeofoffense HdmsS11W43RJbI5GI- Where
l (W When
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What happened to the charge? (Circle
vie
2
Convicted N Dismissed Deferred Suspended Plead Guilty
Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
Where
Other
When
onvicte Dismissed Deferred Suspended Plead Guilty Other w
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? tV
Type of offense
Where
When
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)
WAIT&
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby celflify that I have issued to me by the Iowa Dep rtme t of Transportatio a valid h ffeur's license number
issued onexpiring on 27 1 understand that if
falsely answer any questions In this application, that this application may be denied. I agree the 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 -A A I
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STATE OF IOWA )
COUNTY OF JOHNSON
S sc jbed and sworn to before me by A).;n . A - �;� N-�C�i� on this l 1 -,, 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 Chauffeul's license
Signature of P e ief or esignee 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.
Signatur&efCity Cierkordesign
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
C1.M/rNDDRNMDGEAPPL92M4aMd6d.DOC 0312015
0
[Yate
#i4MH#i*****#iff*f*MR*S11Mf***i*hi*+4**41r1f41M*#%**4#hi#*F2#SH*#2****##-fiH: Aii***t#**#**#*aw***#HH####H#*f *tffwlfM.1*f!f!f*MlfffeRR*fYf#Y
Office Use Only
Approved application
DCI report
State certified driving record
Website update
C1.M/rNDDRNMDGEAPPL92M4aMd6d.DOC 0312015
Inquiry
Date:
Customer
Name:
Address:
2/4/2016
5409180
`DDTmmiawadetgov
_
RfATER I SUAP I. ER I CMTOMER P.RIVI N --
Office of Driver Services
PO Box 9204 f Des Mcines, IA 503[6-9204
Fhone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837
wvrx.iov.•adotpov
Certified Abstract of Driving Record
DL/ID it: 248AD4337 CIA) CDL Permit Class: None
Class: D
Ahmed, All Omer Ali Audit #:
2654 ROBERTS RD APT Issue Date:
1A
City/State: IOWA CIN, IA
522462741
Mailing PO BOX 2532
Address:
Mailing IOWA CITY, IA
City/State: 522442532
Date of 9/22/1968
Birth:
Sex: M
Convictions
8961645
03/27/2015
Expiration 09122/2018
Date:
Endorsements: 3
Restrictions: NONE
Restriction None
Supplement:
History Information
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
None
COL Permit
None
Restrictions:
".
ID Status:
None
OL Status:
VAL
CDL Status:
None
CDL Permit
ELG
".
Status:
COL Cert Status:
None
:i
CDL Med Status:
'None
^
_
zr
ry
Atation Date conviction Date ACD Explanation County 3UI2
._..,...... - 1111. 1111 . 1111
1111 1111... 1111. 1111...
19/01/2012 :11/08/2012 ,M14 Fail to Obey TrafNc Sign/Signal :Johnson 'IA
Accidents - Accident Involvement indicated does NOT mean the individual was at fault or given a citation.
5ccident Date_Case idumber JUR
_.,_.__.,.....___...._..... -_..._.1_111._.., - — . , .,_. _1.1.11...... . _ . -. -11-1-
.. -.------------ .......
12/12/2015 895326 IA
Name: Ahmed, All Omer All DL/ID: 24BAD4337
Pursuant to Iowa Code §321.10, I, Kim Snook, 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 1 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:
9.a0'quat i/Gh�4�
FJ an, 26. 20165, 3 50P Cie Div _of Criminal Investigation No, 6155 P. 1/3
------- 01/ms/2095 12: of 0382 P.002/002
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STATE OF IOWA
` Ctiluillal HiSt:ory Record Check ,
Request F'otrm
To: Iowa ))ivision of Criminal luveatigaelnn
SUpperr Qpel'atiotls lioreao, t"Flour
215 r. 71a street
Des Koines, laws 50319
(515) 725-6066
(515) las-6080 Far
11
DC1AccountWomber
(ifapplrea�'
From: City 0floava Clly
City Clerk's Office —
410 L. Wnshin ton Strect
Iowa City YA 32340
Phone: 3IM56-5041
I•'ox: 319356 5497
1J %)w T.
Date of Birth t�maiwam 1 Gender afandata Social Securi Number (.aornmaadu
0 2 ale ❑Female U 7* Li
Ci'nivev'f'foranaffon: Without s signed waiver ftom the subject of the request, a complete criminal history record may riot
be relUsable, per Code of Iowa, Chapter 692.2. Ror co_ mnlate criminal bls[ory record utformad0a, as Allowed re tan{ a may
110
Wall) a waiver i nature from the sub act oil
request.
WalV¢rr<f¢f¢Qre:I Lereby five pumissio-Ilay d¢'bovc re
nesiin ofadal roc nd,
aarnncenr o`;lntlhal is mainuiardhy lt¢bCfmay'berdcased as ales
wcd by law..
Waiver Signature:LADLA-i 2,
_ 1 ,\
Xor�ra Crilninal Histor r Record Check Results W
p1Cl use only)
As of a� a search of the provided ualue and date of birth revealed; ?
No Iowa Criminal History Record found with DCI
Q iowa Crinunal History Record attached, DC.I 8 c;
•a
n..:_r.:_.. a...
DCI -77 (08125110)
Received Time Jan. 25. 2016 10:52AM No. 5983