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Home My WebLink About17-025-4 �III� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 5 2240-1 82 6 (319) 356-5040 (3 19) 356-5497 FAX IDENTIFICATION NO. / -7 - 7-7 --Z-Er (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 First Middle 1. Name (REQUIRED)L�'l 2. Address (REQUIRED) r j Prr S Y �7 3. Contact Information (REQUIRED) Email: urr��Y49�o� Z 1 ajw lo!jt'"gfjCell Phone: (�—written communiEtibn sent via �I �email)�i 4a. Driver's License expiration date (REQUIRED) '® 6 / 0 1 1 I n b. Taxicab Business Name (REQUIRED) i � w 5Q L l R ki 5. Prior experience in transportation of passengers: -1 y rar 3 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /V d 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? Type of offense Where When What happened to the charge? (Circle one) Convic " 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? n/ 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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby c r that I have, issued to me by the Iowa Department of Transportation a valid Driver's license number /_ XQ 1 6_ issued on o i 3 expiring on 4Q 2i /19 . I understand that if I falsely allswer 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 tie City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant I �I Date Vib I 1 STATE OF IOWA ) COUNTY OF JOHNSON ) / �� L 11 11 Sub c ibed and sworn to before me by /�I� �a 6 (o n thisi Y day of � . . WENDV S. IiAAYER .__ Notary Public i nd for the State of I wa 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 /UIf� or 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. Signa o ity Clerk br designee Dat f111!!!11#+#}4#}4#}Y##}yy.}###Y}!Hll11f!!'fi11f!l1111111##}##Y##}44}Y4lf!!#1f!!1f!!1f#Y1!'#1111l1111+#+#}4}44444111f4444H11111.1!!!#+1#Y111M1##1f Office Use Only Approved application DCI report State certified driving record Website update ClerWTA%IDRIVMDGEAPPL92014a nded.DOC 07/2016 C41UWADOT SMARTER 1 SIMPLER I CUSTOMER DRIVEN VVww,lowadot.gov Inquiry Date: Customer Name: 1/31/2017 2345972 Page 1 of 2 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 wwaJo•wadol.gov Certified Abstract of Driving Record DL/ID #: 617XX3816 (IA) CDL Permit Class: None Class: A Abdallah, Elfatih Hussein Audit #: 7169570 Address: 16 ANISTON ST City/State: IOWA CITY, IA 522402216 Mailing 16 ANISTON ST Address: Mailing IOWA CITY, IA City/State: 522402216 Date of 6/21/1972 Birth: Sex: M Convictions Issue Date: 07/25/2013 Expiration 06/21/2018 Date: Endorsements: NT 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: VAL Supplement: CDL Permit ELG 12/03/2011 Status: IA 11/22/2016 CDL Cert Status: Excepted Interstate CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation County IUR D1/13/2013 '02/21/2013 'S92 .Speed Iowa IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 11/20/2008 1472653 IA 06/24/2010 X578332 IA 12/03/2011 _ _ 66053_0 IA 11/22/2016 953877 IA Name: Abdallah, Elfatih Hussein DL/ID: 617XX3816 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: 1/31/2017 Jan. 13. 2011 9:24AM Div of Criminal Investigation No. IM P. 1/1 kroW:Gley of Iowa Cny Clork n((loe 319 3686607 01/10/2017 16:46 117a7 P,002/002 STATE OF 10'VV.A Criminal History Reca rd Cheer I � Request Form To: Iowa Dlvislon of Criminal Investigation support Operations 1lureap, 1" Floor 215 E. 7" Street ...,•lea, .vn� wo.,� (515)725-6066 - (515)925�Oflt1—t+�a-- I MI rnnnP.ctinrt nn Inum Criminal 1Tistnry Record Check on: I)CIAcc(untNumber: L/G��-~ —,.._.elf applicanle) — IWon: City of Iowa Clty City Clerk's Office 410 G. Wasltinglmt strdet Iowa City, IA $2240 Phone; 319-356-5041 Fax: 319-356.5497 Last Name (mandatory) .First Name (mandatory) Middle Name (recommended) Ad -Z-11911 ,r--1rF1 T /'I, H of Birth (mandatary) (`render (amndxtory) Social Security Number (reconuntrded) -Date g6 l)l l i q 72 Male ❑Female Waiver Yirfofaiatioh: Without a signed waiver from (lie subject of the request, a complete criminal history record may not be releasable, per Code oflowa, Chapter 692.2. For complete criminal history record Informotion, as allowed by law, always obtain. a wavers( nature from the subject of the request. Waiver Belease; I hereby give permission for she above requesting official to conduct an louvo criminal histoq• «cord check writ Ore Division orCriminal inressigation(DCI). Any criminal history data concerning me amus main lined by the DCl may be eleased os allowed by lam. Waiversigitatur•e: Iowa Criminal History Record Check Results � • (Da use only) As of a search of llre provided name and date of birth revealed: No Iowa Criminal Histoty Record found with DCI ❑ Iowa Criminal History Record a(tached, DCI , DCI initials ` DCY-77 (06/25/10) Rnrnivcrl Timp _Ian 10 9011 9.96PM No 176R