HomeMy WebLinkAbout17-027CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO.
`)
(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
3. Contact Information (REQUIRED) Email: `_`>a44 q)djhGOal(.cc, r'1Cell Phone: 3t9_3R�_�iel
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) D5 I k 3 ( Z, 20
b. Taxicab Business Name (REQUIRED) C- 1 �G cc --N b
5. Prior experience in transportation of passengers: V 2r�rS
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? No
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?
n
What happened to the charge? (Circle one)
When
Other
lad (o
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? D/[)
Type of offense Where When
�J
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 RtVIEW
i
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 Transportati n a valid Driver's license number
%17n issued onni _73_ c7/ xpiring on * , . 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 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 04
__!!__**______________________#!==!#.flf1!!!f,!!!."!1*'**;FF}4#}#**'****•'*#•#******#•*••*,!!,!!*11**"1i!*"1!*===________*_______*_*_________
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by f7 _ Xb raL.: .a on this l to day of
S. M0, L,Li ,P%t- Qai2�.
VuMber 129428
.. Frnires Notary Public in d for the St 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).
Expiration da of Driv is s
s�zv
Sionahve of P ice C ' desinnee �Da(e
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.
Sig of City Clerk or designee Date
HfIN##fiff!!*14ll4tif!l14184*##tr#####f#llf4flff44if1H1t11!!f!*4!4*f444*#44+#=4+#==#####4M4ff41f11111tf11f4!!1:!ll:tfif4!#*#1�####'#######i####i#
f
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Clerk/rAXIDRIVBADGEAPPL92014amended.DOC 0712016
CIowa Department of Transportation
AW Office of Daww Servtces (TOO Ffee) 8 )O-Ci32-1121
PO Dox 9204, Des Moines, IA 50385-9204 515-244-9124
fA)C 515.239.1897
Certified Abstract of Driving Record
Inquiry Date:
2/14/2017
DL/ID #:
422AF7170(IA)
Customer #:
5609235
Name:
Ibrahim, Saifaldin
Class:
D
ID Status:
None
Omarab
under in 35-55 mph
Address:
2401 BARTELT RD
Audit #:
8788773
DL Status:
VAL
APT 2C
Issue Date:
01/23/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
05/13/2020
CDL Cert Status:
None
522462701
Endorsements:
2
CDL Med Status:
None
Mailing Address:
2401 BARTELT RD
Restrictions:
NONE
Restriction
None
APT 2C
Supplement:
Date of Birth:
5/13/1960
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522462701
History
Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
09/08/2016
09/13/2016
S92
Speed (10 mph &
Tama
IA
under in 35-55 mph
zone
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Accident Date
Case Number .
JUR
106/1Z12013
744204
IA
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170
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:
2/14/2017
IOWA
f Office of Driver Services
Iowa Department of Transporation
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170
ry
!F�
crI
Feb.13. 2017 9:44AM Div of Criminal Investigation o2.,olZo,� o®.No.3562 s2 P.�1/2ZlOO2
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STATE OF IOWA
Criminal History Record Check
Request Form
To: Iowa Division of Criminal Investigation
Support Operations Bureau, I" Floor
215 E. 7'h Street
DesMolnes,Towa 50319
(515) 725-6066
(515)725-6080 Fax
I am renuestine an Iowa Criminal History Record Check on:
CCI Aocounl Number: 17��-") .F
(if rltplieable)
Froin: City of Iowa City
City Clerk's Office
410 r, Washington Street
Iowa City, TA 52240
Phone; 319-356-5041
Fax: 319-356-5497�-
Last Name (mandatory)
First Name (mandator)
Name (scca,=ended)
TT90 H EM
_Middle
5 NT_I-ALDIrV
D1gWpite
Date of Birth (mandatory)
Gender (mandator)
Social SecuritX Number (nccmaawded
6To
Uwe ❑Female
l 6`� —S 66
Waiver InformatiDn: Without a signed waiver from lite subject of the request, a complete criminal history record nsay not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed bylaw, always
obtain a waiver signature from the subject of the request.
- Waiver Release:! hcrebygive pcnnlsslan for she abavc requesting ofaciat to conduct m Iota uiminel history rcwrd cheek niTh the Division ofComind
Investigation (DO), Any criminal history dem eoneamins me that is maintained by The DO maybe released as allowed by la/se..
Wetivei-Mgnature:
V _
Iowa Criminal History Record Check Results (ocloseonly)
As of a search of the provided name and date of birth revealed:
:i
No Iowa Criminal History Record found with DCI "`" cy`
Iowa Criminal History Record attached, DO
DCI initials
DCI -77 (08/25110)
Received Time Feb. 10. 2017 8:42AM No, 3448